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

Existing In-patient Drug Administration Procedure3.1 The existing drug administration procedure consists of a number of sequential actionscarried out by doctors, nurses and pharmacists. The ideal sequence should be the doctorinitiates and writes drug order, the pharmacist reviews the order and supplies the drugs,the nurse administers the drugs to the patient.3.2 The following flow chart indicates the sequential steps of the existing in-patient drugadministration process, from ordering, through dispensing to administration. Each step hasits own unique opportunities for error. Most of the steps are critical control points, whereunchecked errors at those points can lead to a chain of errors.Prescriber initiates the drug orderPrescriber writes the drug orderPrescriber initiates the drug orderExisting Problems:• Patient information such as medical history,patient biodata & drug history includingdrug allergy, is needed in initiating a drugorder and might not be readily available.• Drug information might not be easilyavailable at the time when it is needed.Prescriber writes the drug orderExisting Problems:• Illegible handwriting.• Use of non-standard drug nameabbreviations.• Dose of medication is not in exact dosage.• Unclear abbreviations for time of drugadministration, e.g. q.d. & q.i.d.• Use of non-standard abbreviations for theroute of administration.• Intravenous drug order not available forpharmacy for vetting.• Different interpretation of “start date” onthe drug order.12