Page 65 - Q BULLETIN, Ministry of Health Malaysia, VOLUME 1, NO. 31 (SUPPLEMENT 1), JAN-DEC 2022

Q Bulletin, Volume 1, No. 31 (Supplement 1), Jan - Dec 2022
th
11 National QA Convention, 4 – 6 October 2022
PP-27

Reducing the Percentage of Transcribing Errors in the Pharmacy Information System
(PhIS) at Pharmacy Departments under Pejabat Kesihatan Daerah Kampar

Nor Zuraida AW , Tang XH , Nur Amirah D , Nor Aimi Liyana O ,Nooratiqhah A , Nurul Nadia JS 4
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1 Pejabat Kesihatan Daerah Kampar, Perak
2 Klinik Kesihatan Kampar, Perak
3 Klinik Kesihatan Gopeng, Perak
4 Klinik Kesihatan Malim Nawar, Perak
SELECTION OF OPPORTUNITIES FOR IMPROVEMENT:
Transcribing errors may occur when transferring information from manual prescriptions into an electronic
system known as a Pharmacy Information System by pharmacy personnel. In August 2020, out of 6224
prescriptions received at the Pharmacy Departments under PKD Kampar, 361 (5.8%) prescriptions with
transcribing errors were detected.

KEY MEASURES FOR IMPROVEMENT:
The indicator is the percentage of transcribing errors in PhIS at the Pharmacy Departments. The standard is 0%
as per in the Manual for Quality Assurance Program (QAP) Indicators.

PROCESS OF GATHERING INFORMATION:
This quality improvement study was conducted in two cycles from October 2020 until June 2021. Pre-designed
data collection and Daily QAP1 Reporting Form are used to record the transcribing errors and contributing
factors. All new prescriptions received were included. The data were analysed using Microsoft Excel.

ANALYSIS AND INTERPRETATION:
A total of 55 (0.8%) transcribing errors were detected during the pre-intervention phase. Most of the identified
contributing factors were overlooked on the changes in the patient’s drug regimen (89.1%), followed by
inadequate training of PhIS (3.6%), unconducive working area (3.6%) and shortage of manpower (1.8%).
There were 63.6% of errors which involved the same medications.

STRATEGIES FOR CHANGE:
An innovative Tagging Sticker was established to notify and visualise prescription changes. A list of medications
frequently transcribed wrongly was placed at the top of PhIS computers. Hands-on session and Continuing
Medical Education about transcribing errors were conducted. The workspace layout was rearranged to be
more ergonomic. Staggered Time Appointment System and establishment of the Google Sheet for Daily Staff
Movement were introduced.

EFFECT OF CHANGE:
The percentage of transcribing errors was reduced in cycle 1 from 0.8% to 0.4% and 0.3% in cycle 2. The
medications often involved in transcribing errors had reduced from 5 to 2 types.

THE NEXT STEP:
To audit six monthly and reinforce strategies towards achieving the standard for transcribing errors in the
future.

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