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

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ForewordMedication safety and provision of quality care to patients are the first and foremost priority in thedelivery of medical services of the Hospital Authority. Towards this aim, the Hospital Authority hasfor years been maintaining a close watch on the high risk areas of the drug administration systemwhich may require improvement or change in practices. In 2000, the <strong>Report</strong> on DrugAdministration Procedures and Practices was published. Since then, the 2000 <strong>Report</strong> has beenvalued as an indispensable piece of guidance for the medical, pharmacy and nursing staff in theHospital Authority.However, with the passage of time, the advancement in new technology leading to more complextreatment protocols and the increasing public demand for high quality services, new issues and newpotential risk areas continue to emerge in the drug administration process. Thus, in 2004/<strong>2005</strong>,medication incident has become one of the priority areas in the annual plan of the RiskManagement Committee. A working group was appointed by the Risk Management Committee toreview commonly occurred medication incidents in the Hospital Authority and to makerecommendations for improving patient safety. As a step forward, the working group was alsogiven the task by the Drug Utilization Review Committee to review the 2000 report founding on thespirit and principle of the recommendations.The essential theme of the recommendations is to nurture a culture of high quality patient care withzero medication incidents as the ultimate goal of all personnel involved in the drug administrationprocess. Medication incidents do occur for a variety of reasons and at almost every stage of the drugadministration process. With the increasing complexity in treatment protocols, the possibility andfrequency of the occurrence of medication incidents will correspondingly increase. Maximumawareness of each health and medical professionals involved in the drug administration processwould be one of the important factors to reduce medication incidents. Standardisation of proceduresand their strict compliance will also help to minimize medication incidents. Risk management thuscalls for the highest vigilance of every one of us.With the above in mind, the Working group had carried out a comprehensive revision of the 2000<strong>Report</strong>. The revised guidance will help to make medicine safer for all the patients.Dr. W L CheungChairman, Drug Utilization Review Committee1
Executive SummaryIn 2000, the <strong>Report</strong> on Drug Administration Procedures and Practices was published. A set ofrecommended practices and requirements were drawn up with respect to all the then identified riskareas in the drug administration process. The 2000 <strong>Report</strong> has already laid a good foundation forsafe medication.In mid 2004, a working group comprising of medical, pharmacy and nursing staff from differentclusters was set up with two objectives. The first one is to identify gaps between the recommendedprocedures and the actual practices and to make recommendations for improvement. The secondobjective is to review and update the 2000 <strong>Report</strong>. The <strong>2005</strong> <strong>Report</strong> on Drug AdministrationProcedures and Practices is thus an updated version of the 2000 <strong>Report</strong>.To maintain easy reference, the <strong>2005</strong> <strong>Report</strong> adopts substantially the same format and layout of the2000 <strong>Report</strong>.Chapter 1 outlines the composition, terms of reference and objectives of the working group.Chapter 2 provides an overview of the progress on the implementation of the recommendations ofthe 2000 <strong>Report</strong>.Chapter 3 identifies those areas where improvements are needed in the drug administration process.Satellite Pharmacy model and the Cluster Pharmacy model which have been operating for sometime in certain hospitals are included in addition to the conventional In-patient model for in-patientdrug administration review.Chapter 4 consolidates the updated recommendations on the different procedures and practices inthe drug administration process. The recommendations on certain high risks areas have beenemphasized and strengthened. The high risk areas are, for example drug allergy, electronicprescribing on discharge prescription, drug repackaging and drug replenishment. New evolvingareas such as management of drug samples, handling of specific drug groups, hazardous chemicals,resuscitation medications and Chinese Medicine are also included.Chapter 5 sets out various Quality Assurance Programmes regarding Drug Therapy Administrationwith specific highlights on the implementation of the Advanced Incidents <strong>Report</strong>ing System (AIRS).2
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 10 and 11: CHAPTER TWOTHE PROGRESS REPORT2.1 P
Page 12 and 13: CHAPTER THREEAREAS FOR IMPROVEMENT
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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
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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
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APPENDICESAppendix 1Appendix 2Appen
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Hospital Authority Hospital No. : I
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Sensitivity:Prescription/ routewith
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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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