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

QUALITY ASSURANCE IN DRUG THERAPYHOSPITAL AUTHORITY MEDICATION INCIDENTS REPROTING PROGRAMMEPurpose1. This memo announces the setting up of the Hospital Authority’s Medication Incidents<strong>Report</strong>ing Programme and its implementation.Background2. The goal of any drug therapy is the achievement of defined and desired therapeuticoutcomes with minimal side effects and “risks” to the patients. “Risks” in the course ofdrug therapy may arise because of “adverse reaction” to drug appropriately prescribed andproperly administered. Alternatively, patient may suffer from medication errors which arepreventable through effective systems controls and implementation of sound proceduralguidelines.3. In the course of reviewing the drug delivery systems in public hospitals, the “WorkingParty on Drug Administration Procedures and Practices” has considered in detail, thecausation and prevention of medication errors, and the principles involved in the settingup and operation of any monitoring mechanism on medication errors.4. The feasibility of having a Medication Incidents <strong>Report</strong>ing Mechanism for HospitalAuthority has since been discussed at the HA’s Central Drug and TherapeuticsCommittee. Further and more intensive discussion by professional staff in Hospitals havealso been promoted by the publication of Hospital Authority Drug Education BulletinIssue No. 4 and the organisation of a series of 3 seminars on the subject in October 1993.Medication incidents reporting5. It is certainly important to take proactive measures to prevent medication errors byimproving procedural guidelines, staff education and system support. It is equallyimportant that we can learn retroactively through errors that have been committed. In thisregard, there are sound support from overseas experience, for a medication incidentsreporting mechanism to be in place in all in-patient health care facilities so thatmedication incidents could be identified and documented and their causes studied in orderto develop systems that minimize recurrence. A variety of different reporting mechanismsare being used overseas in health care facilities. They may differ in the definition of casesto be reported, the reporting format, details of inquisition and the approach taken to dealwith the staff and patients involved.6. It is held however, that any effective incident reporting system should stress the qualityassurance and constructive aspect of the process and avoid a punitive or disciplinaryapproach. In this regard, the Hospital Authority already have appropriate procedures inplace to deal with serious cases of medication error which warrant medical-legalconsiderations. Immediate assistance could be solicited from the Legal Liaison Officersat HAHO in accordance with HAHO General Administration Circular No. 2/92.7. Recognizing the need and benefit of medication incidents reporting and monitoring, anumber of HA Hospitals have already set up their own reporting systems within the lastyear.1