Proceedings of the 12th European Conference on Knowledge ...

6. Case analysis
Tony K. M. Lo and Patrick S.W. Fong
6.1 The case: Medication Incidents Reporting Programme (MIRP) by Hong Kong
Hospital Authority (HKHA)
Established as a statutory body in 1990, <strong>the</strong> HKHA manages all <strong>the</strong> public hospitals in Hong Kong.
The MIRP started in 1994 with a view to identifying opportunities for quality improvement in
medication and to assisting healthcare pr<strong>of</strong>essionals in reducing <strong>the</strong> chance <strong>of</strong> reoccurrence <strong>of</strong>
medication incidents. Since its inception, <strong>the</strong> MIRP has published 25 bulletins, which are available for
download at <strong>the</strong> following website:
(http://www.ha.org.hk/visitor/ha_visitor_index.asp?Parent_ID=367&Content_ID=676). Under this
programme, public hospitals are required to submit quarterly statistical returns and information about
any medication incidents to HKHA’s head <strong>of</strong>fice for analysis and consolidation. It is basically a
voluntary self-reporting system. Nursing personnel, pharmacy staff, doctors and o<strong>the</strong>r staff coming to
<strong>the</strong> knowledge <strong>of</strong> medication incidents can make reports <strong>of</strong> incidents. In order to encourage reporting,
<strong>the</strong> identity <strong>of</strong> <strong>the</strong> staff and patients involved in <strong>the</strong> incident are not required to be disclosed. Reported
cases are directed to <strong>the</strong> Hospital Drug Committee and reviewed by a panel consisting <strong>of</strong> doctors,
pharmacists and nurses appointed by <strong>the</strong> Committee. The Committee identifies <strong>the</strong> underlying causes
<strong>of</strong> incidents and recommends appropriate preventive or remedial measures, which are <strong>the</strong>n published
in <strong>the</strong> MIRP bulletins distributed to HKHA’s staff and made accessible to <strong>the</strong> public. The MIRP
bulletins, written in English, are typical textual documents <strong>of</strong> lessons learned. While <strong>the</strong> style and
format <strong>of</strong> <strong>the</strong> MIRP bulletins have been modified over <strong>the</strong> years, <strong>the</strong> structure <strong>of</strong> its content remains
basically unchanged and consists <strong>of</strong> 3 main areas: <strong>the</strong> main topic, case sharing and statistics. An
issue is usually 4 to 5 pages long. The main topics cover a wide range <strong>of</strong> <strong>the</strong>mes from <strong>the</strong> mechanism
<strong>of</strong> <strong>the</strong> MIRP to <strong>the</strong> identification <strong>of</strong> high-risk areas in <strong>the</strong> drug administration process. Cases for
sharing are medication incidents or near misses <strong>of</strong> medication errors, e.g. drugs issued to <strong>the</strong> wrong
patient, dose miscalculation, unattended medication, etc. Statistics are numerical information
including <strong>the</strong> distribution <strong>of</strong> incidents (by error type, by attributed cause and by severity). There are
also o<strong>the</strong>r error reduction tips and news, and a message to readers.
6.2 Evaluation based on question checklist
We select MIRP bulletin issue no. 25, published in July 2010, as an example for analysis. In this
issue, five cases <strong>of</strong> medication errors are reported as events for lesson learning. For illustration
purposes, <strong>the</strong> questions suggested in <strong>the</strong> above sections are used to reveal <strong>the</strong> context richness,
experience sharing and reflective thinking <strong>of</strong> <strong>the</strong> content <strong>of</strong> this issue. The questions and our brief
analyses are shown in Table 2.
Question
Context richness
What kinds <strong>of</strong> content-independent and
content-dependent contexts does <strong>the</strong> lesson
mention?
Does <strong>the</strong> lesson explain how <strong>the</strong> author
identified and captured <strong>the</strong> knowledge?
Does <strong>the</strong> lesson state who <strong>the</strong> target
learners are?
Analysis
The processes <strong>of</strong> lesson identification, capturing and
sharing are not found in this issue (no. 25), but <strong>the</strong>
mechanisms <strong>of</strong> <strong>the</strong> MIRP were explained in detail in <strong>the</strong>
first few issues published in 1994 and 1995. Leaners
may not be aware <strong>of</strong> <strong>the</strong> mechanism if <strong>the</strong>y have not
read <strong>the</strong> first few issues. The mechanism is a bottom-up
process relying on submission <strong>of</strong> information from
individual hospitals. However, <strong>the</strong> criteria for identifying
potential lessons and how <strong>the</strong> knowledge is captured
(e.g. by interviews or by an inquiry committee) are not
mentioned.
The exact time and place <strong>of</strong> <strong>the</strong> occurrence <strong>of</strong> individual
events are not given in MIRP bulletin no. 25. Yet
learners can deduce from <strong>the</strong> content where <strong>the</strong> event
happened, say, in a ward or dispensary. It is also
reasonable to assume that <strong>the</strong> events happened within a
few months prior to <strong>the</strong> publication date.
The bulletin does not say explicitly who <strong>the</strong> main
audience is. Given that <strong>the</strong> content is written in English,
with many pr<strong>of</strong>essional terms, it is obvious that it is
intended for pr<strong>of</strong>essional staff such as medication
nurses, doctors and pharmacy staff, who are
responsible for medication.
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