2005 Edition Report on Drug Administration Procedure & Practices ...

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CHAPTER TWOTHE PROGRESS REPORT2.1 Progress <strong>Report</strong> of HA Hospitals based on the 10 Recommendations of the <strong>Report</strong> onDrug Administration Procedures & Practices (2000 <strong>Edition</strong>)No. Recommendations Current Status (December 2004)IIIIIIIVVHAHO should encourage thepromulgation, dissemination &implementation of therecommended practices &procedural guidelines in the2000 <strong>Report</strong> on DrugAdministration Procedures andPractices in Public HospitalHospitals DTC should adopt theprocedural guidelines andpromulgate them at the localhospital level. Following theiradoption the DTC shouldcommence the continuousreview of staff adherence tothese guidelines.Hospital should follow theCentral list of HA-wideapproved/standard abbreviationsin prescribing.Hospitals should review theModel Intravenous (IV) Fluid &Drug Additives AdministrationForm. They should reassesstheir existing hospital IV drugadministration forms and makeany modifications necessary.Hospitals should seek tooptimize turnaround times andprevent any possible tamperingor losses during the process ofdrug delivery to wards.• A presentation had been made to all HCE in the HCE RoundtableMeeting in January 2000.• A briefing session of the <strong>Report</strong> had been held for all DTCchairpersons and representatives from pharmacy and nursingsections in April 2000.• Pocket version of the Drug Administration Procedures andPractices was published and distributed to all medical, pharmacyand nursing staff in 2000.• Hospitals are required to report the level of compliance to therecommendations of the <strong>Report</strong> on Drug AdministrationProcedures and Practices (2000) as stipulated in HA Annual PlanSection 3 Standard 29 (Medication Use). <strong>Report</strong>s should besupported by DTC minutes and evidence of relevant auditprogrammes / documents.• A central “List of HA-wide Approved / Standard Abbreviationsin Prescribing” consisted of standard abbreviations for drugnames, routes of administration, drug administration frequenciesand dosages was drawn up and included in both the standard andpocket versions of the <strong>Report</strong>.• A model “IV Fluid and Drug Additives Administration Form”was recommended to the Hospital DTCs for appropriatemodification of their hospital IV drug administration form.• Various designs of drug receptacles to be used for drug deliveryhad been sourced and recommended to the hospital pharmacies.• Hospital pharmacies were recommended to review their drugtransportation process and rectify deficiencies which couldpossibly result in misappropriation or tampering of drugs.VIHospitals should prioritize theirresources for the purpose ofensuring the safe drug use,improving the efficiency of drugdistribution systems and thequality of patient care.• Round-the-clock pharmacy service was introduced in QMH,PMH and TMH in Oct 2001.• Clinical Pharmacy Service was introduced as an on-goinginitiative in various hospitals at the ward level of nephrology unit,critical care unit, paediatrics unit, oncology unit etc, and satellitepharmacies were established in PYNEH, PMH, TKOH and TMH.• Clustering of the aseptic dispensing services, in-patient drug9
No. Recommendations Current Status (December 2004)VI (continued) distribution and drug procurement was developed along the lineof the cluster development plan to improve the efficiency of thedrug distribution systems.• The current IT system was continuously updated to facilitate drugadministration processes in patient care: -‣ Individual patient dispensing for in-patients including CARS,non-CARS and Aseptic Dispensing (TPN dispensing,Cytotoxic dispensing and CIVAS)‣ Ward stock processes including barcode topping up system‣ Discharge / Out-patient dispensing (GOPD, SOPD, Staff,A&E ) including PMS-OP, MOE system, EDS, RefillPrescription, Pre-pack Label and MOEMET‣ Computer-linked automated dispensing system, namely BakerCell Dispensing System (introduced in various hospitalpharmacies) and Robotic Prescription Dispensing System(introduced in LKSSC and YOOPD in Mar 2002)‣ With the introduction of the CDDH in PMS & CMS in 1996and 1999 respectively, patient’s medication dispensing historycan be made readily available in PMS and CMS.VIIMedical, nursing and pharmacystaff should keep abreast of thefast changes in the field ofmedicine, drug therapy &related technology, to enablethem to be competent inproviding a professional service.VIII Hospitals should comply withthe Medication Incident<strong>Report</strong>ing Programme (MIRP)with the aim ofminimizing/preventing theoccurrence of medicationincidents.• On-going education in the form of seminars, lectures andworkshops has been organized, and various drug informationleaflets have been produced by HAHO and local hospitals.• Drug bulletins such as Drug Education Bulletin and New ProductBulletin are published on an on-going basis; and DrugInformation Leaflets on Asthma, Cardiovascular Disease,Diabetes, Parkinson’s Disease and Renal Disease have beenpublished by the HAHO.• MIRP Bulletins are published on an on-going basis at half-yearlyinterval by the HAHO, and 19 bulletins have been published atpresent.• “Insulin Administration / Blood Glucose Monitoring Form” and“Intravenous Insulin Administration Form” were recommendedby the insulin working group convened by HAHO to the hospitalDTCs with the aim of minimizing medication incidents.• Electronic reporting of medication incidents through AIRS isbeing implemented in phases since 2002.IXXA standard reportingmechanism/format to beestablished to collectinformation on Adverse DrugReactions (ADR) fromhospitals.Individual hospitals to set upaudit programmes to monitorstaff adherence to the variousguidelines.• The ADR <strong>Report</strong>ing Programme was established andimplemented in October 2001.• Hospitals are required to report the level of compliance to therecommendations of the <strong>Report</strong> on Drug AdministrationProcedures and Practices (2000) as stipulated in HA Annual PlanSection 3 Standard 29 (Medication Use) supported by DTCminutes and evidence of relevant audit programmes / documents.• Compliance of hospitals to the <strong>Report</strong> will be monitoredperiodically in the Service Management Meeting (Pharmacy).10
Page 2 and 3: ForewordMedication safety and provi
Page 4 and 5: Chapter 6 summarizes the specific r
Page 6 and 7: Chapter 6Conclusions and Recommenda
Page 8 and 9: CHAPTER ONETHE WORKING GROUPMEMBERS
Page 12 and 13: CHAPTER THREEAREAS FOR IMPROVEMENT
Page 14 and 15: Existing In-patient Drug Administra
Page 22 and 23: CHAPTER FOURRECOMMENDED PRACTICES A
Page 24 and 25: Drug Name4.11 There should be a hos
Page 26 and 27: Electronic prescribing (Medication
Page 28 and 29: 4.46 When the use of CM is permitte
Page 30 and 31: cytotoxic and central intravenous a
Page 32 and 33: 4.72 Special precautions should be
Page 34 and 35: 4.84 To prevent mixing up medicatio
Page 36 and 37: The Principle of Three checks and F
Page 38 and 39: 4.111 Three-way (red and blue) and
Page 40 and 41: or their discharge or death, should
Page 42 and 43: operational requirement but also it
Page 44 and 45: Quality Complaints on Pharmaceutica
Page 46 and 47: LEVELSHAHOCE / DTOOLS & MECHANISMDU
Page 48 and 49: Medication Incident Report<
Page 50 and 51: Continuing Education6.18 In order t
Page 52 and 53: APPENDICESAppendix 1Appendix 2Appen
Page 54 and 55: Hospital Authority Hospital No. : I
Page 56 and 57: Sensitivity:Prescription/ routewith
Page 58 and 59: Appendix 3aLists of HA-wide Approve
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DRUGTeniposideABBREVIATIONVM-26Thia
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Appendix 3b“Do Not Use Abbreviati
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Appendix 4Schedule for the Administ
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Appendix 5Mechanism for the Managem
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4. As with all medications, there s
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Appendix 6HA Guideline on Safe Mana
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2.1 Concentrated potassium chloride
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Appendix 7Supply of Antidotes and D
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複本 Antidotes and emeg drug lis
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Appendix 8Guidelines for Supply of
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substitution with other drugs in ac
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Appendix 9Samples of the Line Label
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Appendix 10Guidelines on the use of
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Appendix 11Guidelines on Patient Se
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Operational Guidelines7. The operat
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COC(N) Paper 12/2004Approved by COC
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7.4 Evaluation Record and report th
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DISPOSAL OF HOSPITAL PHARMACEUTICAL
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Appendix 14Guidelines on the Handli
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Appendix 15Medication Incident <str
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Hospital Authority Medication Incid
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QUALITY ASSURANCE IN DRUG THERAPYHO
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Fig. 1: ADR voluntary reporting sys
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PROCEUDRE FOR QUALITY COMPLAINTSONP
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Part II Procurement Section, CPO1.
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