Authors (including presenting author) :
Cheng BW(1), Kwok MLA
Affiliation :
(1)Department of Surgery, Shatin Hospital
Introduction :
In Department of Surgery, SH, during the period from May to October 2021, there were 2 medication incidents which related to wrong dose of oral dangerous drug (DD) was administered to patient. After investigation, independent double check was not carried out properly. To seek for improvement, an improvement program was carried out.
Objectives :
To improve staff awareness on independent double check of 3 checks 5 rights on oral dangerous drug administration. To minimize medication incident in Department of Surgery, SH
Methodology :
The methodology included Part I and Part II. Part I : To explore staff performance on independent double checking of 3 checks 5 rights on oral dangerous drug by simulation. All nursing staff (NO/APNs/RNs/ENs) were invited for the simulation: to perform AOM of oral dangerous drug (Clonazepam) and will be the 1st checker on drug checking. WM will be the 2nd checker. Wrong dose of drug (Clonazepam) will be taken out by the 2nd checker. Staff performance will be observed and recorded. Part II: Provide refresher training for staff. Result and findings of Part I were shared to all nursing staff. Medication incidents in SH with learning points were shared. Revision of independent double check performed.
Result & Outcome :
The program was carried out from Dec, 2020 to Feb, 2021. Total 32 staff participated the simulation. 6 staff were found failure to detect the wrong dose of drug which was taken out by the 2nd checker. Non-compliance of independent double check was noted. Staff who failed to perform proper independent check felt surprise on their own performance. After the program: 1. Staff agreed that their awareness on independent double check (on dangerous drug) was increased. Staff agreed that the findings of the simulation was impressive and very useful to understand more on their own performance. 2. Number of medication incident (MI) was decreased. No MI occurred in 2021.
