SITI RABI’ATUL ‘ADAWIYAH BINTI NASRI
PHARMACIST UF48
HOSPITAL TUANKU JA’AFAR SEREMBAN
Reducing Percentage of Errors on Inotropes Usage in Medical Wards Hospital Tuanku Ja’afar Seremban (HTJS)
1
GROUP MEMBERS
Siti Rabi’atul ‘Adawiyah binti Nasri
Pharmacist UF48
(Leader)
Nurhayati binti Abd Samad
Pharmacist UF48
Wong Min Choo
Pharmacist UF48
Lydia Lim Sung Min
Pharmacist UF48
Anaanthan A/L Bhuvanendran Pillai
Pharmacist UF48
Dr Nadiah binti Mohd Noor
Consultant UD56
Maridah binti Mohd Hashim
Matron U36
2
Determine your Real Reward
PROBLEM IDENTIFICATION
High errors on inotropes usage in medical wards HTJS
1
High incidence of improper handling on liquid preparation
Low feedback for 72 hours antibiotic review
2
3
3
73%
48%
52%
Problem | S | M | A | R | T | Total |
High errors on inotropes usage in medical wards HTJS | 21 | 18 | 19 | 14 | 14 | 86 |
High incidence of improper handling on liquid preparation | 18 | 16 | 14 | 7 | 10 | 65 |
Low feedback for 72 hours antibiotic review | 16 | 13 | 11 | 10 | 12 | 62 |
Rating Scale 1=Low, 2=Medium, 3=High
SMART Criteria
PRIORITIZATION OF PROBLEM
Group Members
4
High errors on inotropes usage in medical wards HTJS
REFINED TITLE
Reducing percentage of errors on inotropes usage in medical wards HTJS
High Errors on Inotropes Usage in Medical Wards HTJS
Total errors detected on inotropes usage | Total potential errors on inotropes usage | Percentage |
135 | 184 | 73% |
6
SMART
Remedial measures can be implemented
Remediable
Measurable
Appropriateness
Seriousness
Can be completed within short period of time
Timeliness
High amount of errors
on inotropes usage (73%)-April 2016
S
M
A
R
T
REASON FOR SELECTION
7
TERMS | DEFINITION |
Inotropes |
|
Prescribing Error |
|
Labeling Error |
|
Preparation Error |
|
Dose Error |
|
Medication Error Reporting System (MERS) User Manual 2017, Pharmaceutical Services Division, MOH
TERMS & DEFINITION
8
SITUATIONAL ANALYSIS
01
High Alert Medication
04
Malaysian National Medicines Policy
03
Rancangan Malaysia ke-11
02
Malaysian Patient Safety Goal
05
Pharmacy Programme Strategic Plan
Zero error
1.Guidelines on Safe Use High Alert Medication. 2011 1st Edition. Pharmaceutical Service Division Ministry of Health Malaysia
2. KPI No.11 Patient Safety Goal No.7 To Ensure Medication Safety. Malaysian Patients Safety Goals Guideline.
!!!!
Death
Error
Prolong hospitalization
Inotrope
Permanent Disability
Impact
Extravasation
Inotrope error is among the top 10 causes of overall mortality worldwide.
(RP MAHARAJAN)
LITERATURE REVIEW
R.P.Mahajan. Medication errors: can we prevent them? British Journal of Anesthesia 2011
10
Medication Error
Literature Review
7000-9000 people die each year as a result of medication error
(K.Dillip et al)
Increase cost of treatment
(Chen et al)
Total cost for medication associated errors
>$ 40 billion/year
(Rayhan A. Tariq and Yevgeniya Scherbak)
(Rayhan A. Tariq and Yevgeniya Scherbak)
Wrong Unit
No unit
Only label drug name
No label
Observational survey done by clinical pharmacist in January 2016 showed:
💉Inotropes were given as random, variety practices
💉Lots of errors related to inotropes usage
💉No standard protocol in regards to inotropes
Wrong unit
Not using medication chart
No unit
Only label drug name
No label
PROBLEM STATEMENT
Example of Scenario
Patient A weight 50kg was prescribed with Noradrenaline 10mcg/min.
Staff nurse dilute 1 ampoule (4mg) Noradrenaline with 50ml Normal saline.
Staff nurse run 10ml/hr.
Prescribing error
No label at all
Preparation error
Labelling error
Dose
error
13
CAUSE-EFFECT
ANALYSIS CHART
14
High percentage of errors on inotropes usage in medical wards HTJS
No standardized protocol
Unfamiliarized with proper prescribing, preparation and labelling
Lack of monitoring
Existing protocol not comprehensive
Different practice at different workplace
Not easily accessible
Lack of awareness
Not being displayed
Non adherence to labelling guideline
Lack of knowledge
No sticker
Lack of training
Lack of experience
No counter checking
No charting
Verbally ordered
Time constraint
Non adherence to safe use of high alert medications guideline
No supervision from senior
Heavy workload
Lack of manpower
15
Lack of enforcement
OBJECTIVE
KEY MEASURES
FOR
IMPROVEMENT
17
Most of prescriber only order in BHT
Not using medication chart
Not based on body weight
Inappropriate diluent& dilution
No label@ incomplete label
Confirmation of patients who needed inotropes
(Specialist/Medical officer)
Prescribing of inotrope
(Specialist/Medical Officer/House Officer)
Preparation of Inotrope : Dilute Inotrope
(Nurse)
Infuse Inotrope
(Nurse)
Review patient’s clinical conditions
(Specialist/Medical Officer/House Officer)
Discontinuation of inotropes or regimen change
clinically
responding
clinically not responding
Process of
Care on Inotropes Use
18
Labeling of inotrope
(Nurse)
STEP | PROCESS OF CARE | CRITERIA | STANDARD OF ERROR |
1. | Prescribing of inotrope | In patient prescription need to be filled by prescribers and include data: patient’s name, RN, correct dose in correct unit, date initiation, signature and chop | 0% |
2. | Preparation of inotrope | Dilute with correct diluent | 0% |
3. | Labeling of inotrope | Labeling of the infusion syringe with correct information (name of medication; drug concentration; patient’s name; date and time prepared and name of staff nurse who prepared) | 0% |
4. | Infuse inotrope | Infuse inotrope at the correct dose and rate based on the prescription and patient’s condition | 0% |
MODEL OF GOOD CARE (MOGC)
19
30
INDICATOR
STANDARD
延时符
Percentage of errors on inotropes usage in medical wards HTJS
Malaysian Patient Safety Goal
Patient Safety Goal No. 7
KPI No. 11
20
PROCESS OF
GATHERING INFORMATION
21
Add Title
Study Design
Inclusion
Criteria
Study Period
Exclusion
Criteria
Sampling
Method
延时符
Cross sectional study
Convenience sampling
Patients starting inotropes from other wards then transferred to ward 6A,6B,7A,7B & CCU
Cycle 1
22
Methodology-Study Period (cont.)
May 2016-
October 2016
Remedial Measure
January 2017-
June 2017
Verification
study
Cycle 1
Cycle 2
Cycle 3
Cycle 4
November 2016-
December 2016
Evaluation
July 2017-
September 2017
Remedial Measure
Evaluation
October 2017-
March 2018
April 2018-
June 2018
July 2018-
December 2018
January 2019-
March 2019
Remedial Measure
Evaluation
Remedial Measure
Evaluation
April 2016
23
No | Variables | Data collection tool | Sample |
1. | Percentage of errors on inotropes usage | Data collection form -Observational technique | Patients from medical ward (6A,6B,7A,7B,CCU) HTJS |
2. | Knowledge on proper prescribing, preparation and labelling of inotrope | Questionnaire -Self-administered -10 questions -Adapted from Cairo University & T. Santhipalan study | 25 doctors 25 nurses *working experience more than 3 years |
3. | Awareness on availability of inotrope protocol | Questionnaire -Self-administered -10 questions | 25 doctors 25 nurses *working experience more than 3 years |
4. | Monitoring/ counterchecking | Observational Survey | 40 nurses |
DATA COLLECTION TOOLS
24
ANALYSIS
AND
INTERPRETATION
(Verification Study)
25
26
n=135
N=184
Percentage of Errors on Inotropes Usage in Medical Wards HTJS
Error
Goal for Improvement
To Reduce Percentage of Errors on Inotropes Usage in Medical Wards HTJS from 73% to 0%
Standard 0%
April 2016
Percentage (%)
Percentage of Errors on Inotropes Usage in Medical Wards HTJS
Type of error | Verification (N=46) |
Prescribing error | 41 (89%) |
Preparation error | 20 (43%) |
Labelling error | 30 (65%) |
Dose error | 44 (96%) |
April 2016
27
Contributing Factors on Inotropes Error
Contributing factors on errors in inotropes usage
A-Lack of knowledge
B-No standard protocol
C-Lack of monitoring
D-Prefer current practice
E-Poor attitude
F-Poor communication
G-In-conducive working environment
Pareto Analysis of Contributing Factors on Errors in Inotropes Usage
72%
contribute to errors on inotropes usage
28
STEP | PROCESS OF CARE | CRITERIA | STANDARD OF ERROR | VERIFICATION |
1. | Prescribing of inotrope | In patient prescription need to be filled by prescribers and include data: patient’s name, RN, correct dose in correct unit, date initiation, signature and chop | 0% | 89% |
2. | Preparation of inotrope | Dilute with correct diluent | 0% | 43% |
3. | Labeling of inotrope | Labeling of the infusion syringe with correct information (name of medication; drug concentration; patient’s name; date and time prepared and name of staff nurse who prepared) | 0% | 65% |
4. | Infuse inotrope | Infuse inotrope at the correct dose and rate based on the prescription and patient’s condition | 0% | 96% |
MODEL OF GOOD CARE (MOGC)
29
Percentage of Contributing Factors
88%
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
80%
Lack of awareness on the availability of protocol
Lack of monitoring
38%
30
STRATEGIES
FOR
CHANGE
31
💊Standard Inotrope protocol
💊Standard Inotrope Infusion Chart
💊Standard Inotrope Labelling Sticker
💊Distribute memo
💊Display protocol in medical wards
💊CMEs, CNEs & CPEs
💊Discussion with Head of Medical Department
1
2
💊Publish protocol in HTJS pharmacy bulletin
💊Distribute the bulletin to all department in HTJS
💊Publish protocol in Pharmcube BPF JKN Neg Sembilan and distribute
💊Publish protocol in Medication Safety Newsletter of Pharmacy Service Division, MOH
💊Every inotrope case must consult with ward pharmacist
32
3
💊Revision and update protocol
💊Second edition of the protocol
💊Distribute to all departments in HTJS
4
💊Inotrope mobile application (android app)
💊Rebranding name to My Inotrope PRO
💊Distribute My Inotrope PRO (hardcopy, pdf, android app) to all healthcare facilities in Negeri Sembilan
💊Launching My Inotrope PRO by Director of HTJS
💊Trained ward pharmacist
💊Inotrope roadshow
💊Launching My Inotrope PRO state level
33
STRATEGIES FOR CHANGE CYCLE 1
💊Standard Inotrope protocol
💊Standard Inotrope Infusion Chart
💊Standard Inotrope Labelling Sticker
💊Distribute memo
💊Display protocol in medical wards
💊CMEs, CNEs & CPEs
💊Discussion with Head of Medical Department
34
Main Finding from Verification Study
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
Lack of awareness on the availability of protocol
Lack of monitoring
35
1st edition
Standard Inotrope Protocol
BEFORE
AFTER
36
Problem with existing protocol
Protocol not properly displayed
No reference stated
Dosing not based on body weight
No formula (calculation) from dose ordered to desired infusion rate administered
Table of infusion rate not based on body weight
Difficult to understand
Not everyone followed this protocol
37
38
Emphasize prescribing inotrope based on body weight
Inotrope should be prescribe in mcg/kg/min
Shows diluent compatible
Formula to calculate infusion rate
Provide table of infusion based on body weight
User friendly
Easy to understand
Standard Inotrope Protocol
(First Edition)
39
Precautions
Explain why NS alone cannot be use as diluent
Explain risk of extravasation
Stability
References
Inotrope Labeling Sticker
BEFORE
%
AFTER
Only blank label
Special labelling sticker for inotrope
Following details should be included on the label of inotrope syringe:
Guideline on syringe labelling in critical care areas by Pharmaceutical Services Division MOH
40
On-going CME & CNE session
41
Years | Session of CME/CNE |
2016 | 10 |
2017 | 12 |
2018 | 15 |
2019 | 15 |
CME and CNE
42
Continuing Pharmacy Education (CPE)
Continuous education to pharmacy staffs
Date | Session of CPE |
2016 | 6 |
2017 | 5 |
2018 | 10 |
2019 | 6 |
Main Finding from Verification Study
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
Lack of awareness on the availability of protocol
Lack of monitoring
43
44
Distribute memo
Medical wards HTJS
Memo was distributed to increase awareness regarding implementation of standard inotrope protocol
Display Inotrope Protocol
Standard inotrope protocol was laminated and displayed at place that easily reachable
Main Finding from Verification Study
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
Lack of awareness on the availability of protocol
Lack of monitoring
45
Inotrope Infusion Chart
46
47
Discussion with Head of Medical Department
Head of Medical Department
Enforcing all medical staff practicing proper inotrope usage
Standardized inotrope practice according to standard inotrope protocol
Monitor and supervise staff
STRATEGIES FOR CHANGE CYCLE 2
💊Publish protocol in HTJS pharmacy bulletin
💊Distribute the bulletin to all departments in HTJS
💊Publish protocol in Pharmcube BPF JKN Neg. Sembilan and distribute
💊Publish protocol in Medication Safety Newsletter of Pharmacy Service Division, MOH
💊Every inotrope case must consult with ward pharmacist
48
Main Finding from Verification Study
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
Lack of awareness on the availability of protocol
Lack of monitoring
49
50
Publication in Bulletin/Newsletter
Bulletin Pharmacy Department HTJS
Bulletin Pharmaceutical Services Division JKN Neg. Sembilan
Medication Safety Newsletter Pharmaceutical Services Division, MOH
Create awareness
Dissemination of information regarding inotrope
Main Finding from Verification Study
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
Lack of awareness on the availability of protocol
Lack of monitoring
51
Consult with Pharmacist
52
STRATEGIES FOR CHANGE CYCLE 3
💊Revision and update protocol
💊Second edition of the protocol
💊Distribute to all departments in HTJS
53
Receive request from other wards & departments
Provide protocol convenient to all patients
Main Finding from Verification Study
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
Lack of awareness on the availability of protocol
Lack of monitoring
54
1st edition
BEFORE
AFTER
Standard Inotrope Protocol
(Second Edition)
2nd edition
55
Standard Inotrope Protocol
(Second Edition)
Variable strengths to choose (Single, double and quadruple strength)
Convenient for higher doses and volumes
Caters to patients with fluid restriction
Can be use in all wards and departments
56
Main Finding from Verification Study
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
Lack of awareness on the availability of protocol
Lack of monitoring
57
58
Distribute memo
Memo was distributed to increase awareness regarding implementation of standard inotrope protocol
STRATEGIES FOR CHANGE CYCLE 4
💊My Inotrope PRO (android app)
💊Distribute inotrope protocol (hardcopy, pdf, My Inotrope PRO) to all healthcare facilities in Negeri Sembilan
💊Launching My Inotrope PRO by Director of HTJS
💊Trained ward pharmacist
💊Inotrope roadshow
💊Launching My Inotrope PRO state level
59
Main Finding from Verification Study
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
Lack of awareness on the availability of protocol
Lack of monitoring
60
1st edition
BEFORE
AFTER
61
2nd edition
Android application (Free)
Contain protocol and calculator function
Self developed by team
member
https://bit.ly/myinotropepro
62
63
Body Weight
Dose intended
Range of Dose
Volume of inotrope to be syringe out
Volume of diluent required
Infusion rate to be administered
Auto calculate
CALCULATOR
10 minutes 10 seconds
Main Finding from Verification Study
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
Lack of awareness on the availability of protocol
Lack of monitoring
64
Distribute memo
My Inotrope PRO to all healthcare facilities in Negeri Sembilan
Promotion & Installation My Inotrope PRO
Guide and help doctors, nurses and pharmacist to install My Inotrope PRO
65
Promote Standard Inotrope Protocol
Promote Standard Inotrope Protocol to multidisciplinary staff via computers
(offices, wards and clinics, emergency zones)
Increase accessibility of the protocol
67
Inotrope Protocol and
My Inotrope PRO Launching
Hospital Tuanku Ja’afar Seremban Director
68
Inotrope Launching
Health State Exco (on behalf of Health State Director)
Deputy Health State Director (Pharmacy)
Deputy Health State Director (Medical)
69
Inotrope Road Show
Date | Total road show session |
2018 | 6 |
2019 | 7 |
Create awareness
Dissemination of information regarding inotrope
EFFECT OF
CHANGE
70
Type of error | Verification (n=46) | Cycle 1 (n=114) | Cycle 2 (n=100) | Cycle 3 (n=120) | Cycle 4 (n=100) |
Prescribing error | 41 (89%) | 72 (63%) | 40 (40%) | 26 (22%) | 3 (3%) |
Preparation error | 20 (43%) | 15 (13%) | 5 (5%) | (1.7%) | 0 (0%) |
Labelling error | 30 (65%) | 42 (37%) | 23 (23%) | 15 (12.5%) | 5 (5%) |
Dose error | 44 (96%) | 31 (27%) | 12 (12%) | 6 (5%) | 0 (0%) |
Percentage (%)
Comparison of Errors on Inotropes Usage in Medical Wards HTJS
71
Confirmation of patients who needed inotropes
(Specialist/Medical Officer)
Prescribe inotrope on in-patient medication chart using correct dose/units according to standard inotrope protocol
(Specialist/Medical Officer/House Officer)
Preparation of Inotropes according to standard inotrope protocol
(Nurse)
Appropriate labeling of infusion syringe using inotrope label sticker
(Nurse)
Correct dose of inotropes infused according to standard inotrope protocol and charted on inotrope infusion chart
(Nurse)
Review patient’s clinical condition (Specialist/Medical Officer/House Officer
clinically
responding
clinically not responding
NEW PROCESS
OF CARE EMPHASIZING STANDARD STEPS ON INOTROPES USE
72
35%
20%
10%
2%
Achievable Benefit Not Achieved (ABNA)
Percentage (%)
73
ABNA
ABNA
ABNA
ABNA
ABNA
STEP | PROCESS OF CARE | CRITERIA | STANDARD OF ERROR | VERIFICATION | CYCLE 1 | CYCLE 2 | CYCLE 3 | CYCLE 4 |
1. | Prescribing of inotrope | In patient prescription need to be filled by prescribers and include data: patient’s name, MRN, correct dose in correct unit, date initiation, signature and chop | 0% | 89% | 63% | 40% | 22% | 3% |
2. | Preparation of inotrope | Dilute with correct diluent | 0% | 43% | 13% | 5% | 1.7% | 0% |
MODEL OF GOOD CARE (MOGC)
74
STEP | PROCESS OF CARE | CRITERIA | STANDARD OF ERROR | VERIFICATION | CYCLE 1 | CYCLE 2 | CYCLE 3 | CYCLE 4 |
3. | Labeling of inotrope | Labeling of the infusion syringe with correct information (name of medication; drug concentration; patient’s name; date and time prepared and name of staff nurse who prepared) | 0% | 65% | 37% | 23% | 12.5% | 5% |
4. | Infuse inotrope | Infuse inotrope at the correct dose and rate based on the prescription and patient’s condition | 0% | 96% | 27% | 12% | 5% | 0% |
75
Comparison percentage of contributing factor
Percentage (%)
76
Better
Outcome
Percentage of Contributing Factor
88%→7%
Lack of knowledge on proper prescribing, preparation and labeling of inotrope
80%→0%
Lack of awareness on the availability of protocol
Lack of monitoring
38%→11%
77
Impact
Time Saving
Reduce Cost
78
Cost hospitalization per day for 1 patient
RM80
Complication error happen DUE TO INOTROPE ERROR
Patient stay longer
~1 month
RM2400
If 10 patients develop complication
RM24000
Increase knowledge and productivity
Decision making and work process more efficient
Increase cooperation and collaboration among healthcare provider
Healthcare provider
Increase patient safety
Reduce morbidity & mortality
Increase quality of life (RMK 11)
Reduce cost of treatment by reducing risk of complication error
Increase public confident
Safe country
Impact (cont.)
79
100% staffs satisfied
Appreciation of QA project
Top management
Patient & public
80
Register My Inotrope PRO in Google Play Store & Apple App Store
Conduct a multicentre study regarding inotropes among all hospital in Malaysia
Expand Inotrope Protocol and My Inotrope PRO throughout Malaysia
Next Step
81
Collaboration with Pharmacy Integrated System (PHIS)
Lesson Learnt
Continuous evaluation of remedial measures
Continuous enforcement
Cooperation among healthcare provider as a teamwork
82
References
83
Gantt Chart
Expected
Actual
Acknowledgement
Health State Director
Dato’ Dr Zainuddin Mohd Ali
Deputy Health State Director (Pharmacy) Negeri Sembilan
Pn Basariah Naina
Director of Hospital Tuanku Ja’afar Seremban
Dr Haji Jazari Jamaludin
Head of Pharmacy Department
Pn Ratna Silong
Head of Medical Department
Dato’ Dr Gun Suk Cyn
Dr Noorlita Adam
86
Appendix