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

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