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

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operational requirement but also it will help meeting the clinical needs of users for betterquality patient care.(G) QUALITY ASSURANCE PROGRAMMES4.138 The purpose of quality assurance programmes is to ensure that every drug reaching thepatients is safe, effective and is of quality standard. A number of corporate programmeshave been developed to facilitate the continuous quality assurance of medication use in thehospitals.4.139 These programmes include Medication Incident <strong>Report</strong>ing Programme, Adverse DrugReactions <strong>Report</strong>ing Programme, Quality Complaints on Pharmaceutical Items and DrugRecall.4.140 All medical, pharmacy and nursing staff involved in prescribing, dispensing andadministration of drugs should adhere to the reporting guidelines and procedures asstipulated in each programme for continuous quality assurance. Details of each of theprogrammes are provided in Chapter Five.41
CHAPTER FIVEQUALITY ASSURANCE PROGRAMMESMedication Incident <strong>Report</strong>ing Programme5.1 Medication incidents including “near-miss” cases in HA hospitals should be reported locallyin each hospital using standardised forms. The reporting is on a voluntary basis. Any staffmember encountering a medication incident should be encouraged to make a report,irrespective of whether patients have been involved (refer to Appendix 15).5.2 Completed reports are directed to the hospital DTC or its equivalent which monitors andidentifies the underlying causes for each incident and recommends appropriate preventive orremedial measures to the HCE. The Committee should also report quarterly statistical dataas well as the details of cases of severity index 1-6 to the HAHO using the standardisedreturn forms.5.3 The HAHO will monitor the overall trend of medication incidents and consider appropriatecorporate-wide measures. Apart from this, HAHO also issues MIRP bulletins at half yearlyintervals to HA staff for educational purposes and to the lay press for public accountability.5.4 At the hospital level, each hospital unit is recommended to establish a quality assurance/riskmanagement mechanism. In such mechanism, medication errors would be reviewed andappropriate recommendations and educational programmes would be organized to alert andeducate front-line staff.5.5 <strong>Report</strong>ing of MI by electronic means via the AIRS is being piloted in certain HA hospitalsand will continue to be rolled out to more hospitals of the HA. The value-added factors inAIRS would be the enhanced tools of analysis to assist management in probing root causesof incidents. The promulgation of safety concept and development of learning culturethrough a systematic reporting and reviewing process would be the ultimate goal of the newsystem.Adverse Drug Reactions <strong>Report</strong>ing Programme5.6 The World Health Organisation defines an Adverse Drug Reaction as “any response to adrug which is noxious and unintended, and which occurs at doses normally used in man forprophylaxis, diagnosis or therapy of disease or for the modification of physiologicalfunctions.”5.7 Doctors, nurses and pharmacists must be alert to the potential for or presence of ADR. Astandard procedure to record and report clinically significant ADRs has been established(refer to Appendix 16).5.8 These reports should be reviewed and evaluated on a regular basis, so that any necessaryactions including intervention, documentation, prevention and the provision of educationalfeedback to prescribers and other health care professionals can be done to maximise thesafety of drug use.42
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 10 and 11: CHAPTER TWOTHE PROGRESS REPORT2.1 P
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 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
Page 60 and 61: DRUGTeniposideABBREVIATIONVM-26Thia
Page 62 and 63: Appendix 3b“Do Not Use Abbreviati
Page 64 and 65: Appendix 4Schedule for the Administ
Page 66 and 67: Appendix 5Mechanism for the Managem
Page 68 and 69: 4. As with all medications, there s
Page 70 and 71: Appendix 6HA Guideline on Safe Mana
Page 72 and 73: 2.1 Concentrated potassium chloride
Page 74 and 75: Appendix 7Supply of Antidotes and D
Page 76 and 77: 複本 Antidotes and emeg drug lis
Page 78 and 79: Appendix 8Guidelines for Supply of
Page 80 and 81: substitution with other drugs in ac
Page 82 and 83: Appendix 9Samples of the Line Label
Page 84 and 85: Appendix 10Guidelines on the use of
Page 86 and 87: Appendix 11Guidelines on Patient Se
Page 88 and 89: Operational Guidelines7. The operat
Page 90 and 91: COC(N) Paper 12/2004Approved by COC
Page 92 and 93:
7.4 Evaluation Record and report th
Page 94 and 95:
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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