Game of Zeroes: Zero harm, zero tolerance, zero errors

How an international hospital in Vietnam has zero medication errors related to drug dispensing and administration

Mothers and children are the primary patients at Hanh Phuc International Hospital in Vietnam. Highly sensitive to medication, this patient group equally poses a high risk for medication errors. But the hospital has thus far mitigated this risk, even during the ongoing pandemic.

Hospital Insights Asia speaks with Ms Le Ngoc Tho, Clinical Pharmacist and Pharmacy Quality Manager at Hanh Phuc International Hospital, to uncover best recommendations on a zero harm practice and a zero tolerance system for zero medication errors.

A systemic problem

Ms Le Ngoc Tho, Clinical Pharmacist & Pharmacy Quality Manager

“Medication errors are systemic problems,” this is what Ms Tho wants hospitals to acknowledge in tackling medication errors. Rather than changing behaviours of care providers, hospitals instead need to focus on system errors, although behavioural intervention, such as training and awareness programs, are important in some cases, too.

From January to August 2020, reported medication errors at Hanh Phuc International Hospital are mainly “near misses” in prescription errors and a few adverse drug reactions (ADRs). Prescription errors are commonly caused by inappropriate diagnosis and incorrect medication frequency, route, dose, and instructions.

The system, including physicians, drugs, work environment, and even technology, are related to prescription errors, highlights Ms Tho. Doctors may lack therapeutic training, adequate drug knowledge and experience, and perception of risk. Cases may be too complex. The work environment may lack resources and standardised protocols. Medications can also be confusing, especially those that look alike and sound alike. Further, technologies, like computerised drug information systems in electronic medical records (EMR), may lack clinical decision support programs.

All checkpoints covered

No errors from dispensing and administration mistakes have been reported at Hanh Phuc since January. This is because the hospital was able to identify errors during “near misses” stage, therefore, preventing incorrect drugs from being given to patients, says Ms Tho.

A system like this can be implemented through tracking the entire process from beginning to end, and using root-cause analysis as a crucial part of a zero tolerance system. For Ms Tho, this system is a “multitier intervention process to review medication safety on each step and identify risks proactively.”

Interventions and safeguards at every checkpoint, Ms Tho believes, help identify errors early on. At Hanh Phuc Hospital, such interventions include a review of prescriptions to identify near misses, high alert medication (HAM) colour-coding, double-check of drugs by an independent nurse prior to being administered to patients, and tall-man letters for look-alike-sound-alike (LASA) drugs. Ms Tho’s team annually reviews the hospital pharmacopoeia and the list of HAM and LASA drugs. Gap improvement training and monthly audits are likewise conducted to disseminate awareness for nurses and doctors.

Hospitals can also adopt this same system through interventions for every stage of the process. In the prescribing stage, for example, interventions can include educating healthcare practitioners on safe prescribing and ordering, establishing standard treatment protocols and tracking compliance, performing medication reconciliation before creating medication error and dispensing, reviewing all medication orders and intervening in case of any inappropriateness, and periodically tracking prescription errors and giving feedback to clinicians.

During the storing, preparing, and dispensing stage, Ms Tho suggests interventions such as standardising arrangement and labelling of medications, setting up warnings for high-risk drugs, as well as performing double-checks in all dispensing cases and independent double checks in all steps when using high-risk drugs.

Interventions in the administering and monitoring stage may include applying the eight rights in medication administration (right patient, right medication, right dose, right route, right time, right response, right reason, and right documentation), educating nursing staff on aseptic techniques when preparing medications, tracking nurses’ performance, setting up an online medication error reporting system, and tracking all ADRs occurring through EMRs.

Covering all checkpoints and making sure no mistakes are left unidentified encourage a zero harm practice and a zero tolerance system. Aside from interventions, hospitals would benefit from technological solutions like barcode medication administration system and stronger clinical decision support tools.

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