Authors (including presenting author) :
Chu LM, Yung L, Ng TF, Li HC
Affiliation :
Pharmacy Department, Tuen Mun Hospital
Introduction :
Since 2020, HA pharmacies, based on the latest United State Pharmacopeia, have updated the Liquid Drug Container specifications which provides better UV light protection by using amber color bottle.
Oral liquid drugs dispensing is a high risk task as many different liquid drugs have similar colors and appearance. To reduce the risk, cross-checking procedures was implemented during routine transferring of oral liquid drugs from original bottle into dispensing bottles. However, cross-checking may not be able to prevent all human error, esp. in high workload and multi-tasking situation. From 1 Oct to 30 Nov 2020, there were 12,583 oral liquid drug dispensing records, in which 10,002 (~79.5%) records are ad-hoc pouring into dispensing bottles.
With the introduction of these new bottles, the risk becomes even higher as it is difficult to detect any error once drug is transferred into an amber color bottle during dispensing.
This project studied implementation measures to improve medication safety and operational efficiency.
Objectives :
To improve medication safety and operational efficiency in dispensing oral liquid medications
Methodology :
After analyzing prescribing and dispensing data from Oct–Nov 2020 and consulting major user departments’ opinions, 4 risk mitigation strategies were adopted:
(1) Many commercial drug preparations were in bulk pack size, e.g. 3.6L which requires pouring into another bottle during dispensing. NTWC pharmacy procurement team actively sourced smaller “ready-to-dispense” pack size, e.g. 120ml and 500ml, which can fulfill most prescribing needs.
(2) After agreed by clinical teams and endorsed by CDTC, dispensing quantity is rounded to the nearest whole original bottle size if clinically reasonable and applicable.
(3) For frequently used drugs that only come in bulk pack, repackaging into smaller pack size with unique design auxiliary labels enhances efficient dispensing and easier drug identification.
(4) Commercial drug products usually includes Global Trade Item Number (GTIN) barcodes on label . We created a barcode-matching computer system for drug items. Staff needs to scan barcodes on HA drug dispensing label and commercial product label for checking and matching by the program. If match, a verification label will be printed out.
Result & Outcome :
10203 (~76%) prescription orders were dispensed in a “ready-to-dispense” pack size. The barcode matching system supports identification for over 60% drug items that solution (1) to (3) cannot be adopted. Frontline staff counterchecking was largely reduced, which is safer and more time-saving.
