Aiming for Zero Inpatient Pharmacy (IP) Medication Supply Errors
Care Process & Redesign
Technology
National University Health System Quality Improvement
National University Health System
25 March 2026
Reduce IP supply average error rate to 0.04 or lower for July-December 2024, and sustain this performance through. Regular engagement of ground staff through workgroup and sectional meetings help timely identification and resolution of issues.
Year Submitted: 2025
Published Date: 25 March 2026
Tags: Care Process ＆ Redesign, Operational Management, Supply Chain, Clinical Practice Improvement, Risk Management, Adverse Outcome Reduction, Value Based Care, Safe Care, International Patient Safety Goals, Technology, Digitalisation, Automation
About this Content
Aims
Reduce IP supply average error rate to 0.04 or lower for July-December 2024, and sustain this performance through January-June 2025, establishing a new safety level in medication safety and patient care excellence.
Background
Wrong medication supplies from inpatient pharmacy (IP) to wards threaten patient safety, staff morale, productivity, and hospital reputation. Average error rate increased from 0.05 (January-June 2023) to 0.07 (July-December 2023). While this is still within the current safety target of less than 0.1, this upward trend is concerning. To enhance patient safety and maintain excellence, the aim is to reduce the 6-monthly average error rate to 0.04 or lowera minimum of 20% reduction from best recent performance. This will also positively impact International Patient Safety Goal 3 of the Joint Commission International Accreditation Standards for Hospitals.
Methods
Analysis of contributing factors and root causes, PDSA cycles with 7 different interventions including: bin reshuffling to prevent packing by memory, paired staff returns to prevent wrong drug returns, updated ETP checklist for uniform training, ADC optimization with fast-moving drugs, IPAS automation for fast-moving items, yellow barcode labels for improved visual cues, and registrable barcode updates to reduce manual printing. Regular workgroup meetings, sectional meetings, and multiple feedback channels for near miss reporting.
Results
Average error rate reduced to 0.03 for July-December 2024 and sustained through January-June 2025
Achieved zero error rate in multiple months (July 2024, August 2024, September 2024, October 2024, November 2024, January 2025, February 2025, March 2025, June 2025)
Supply errors reduced following bin reshuffling implementation
Independent double checks reduced return errors
Better clarity for trainers on expectations achieved
Less packing needed and more time saved through ADC optimization
Checkers found yellow labels easier to see as visual cues
Lessons Learnt
Regular engagement of ground staff through workgroup and sectional meetings help timely identification and resolution of issues. Providing multiple feedback channels allow for ease of near miss reporting. Regular reviews of medication trends, collaborations with nursing, constant support and refreshers for staff and monthly communication on performance contributed to sustained changes.
Keywords
medication supply errors, inpatient pharmacy, patient safety, barcode, automation, ADC, PDSA
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National University Health System |
Organization(s) Involved | Ng Teng Fong General Hospital |
Platform(s) | National University Health System Quality Improvement |
Healthcare Professional Group(s) | Healthcare Administration, Nursing, Pharmacy |
Applicable Specialty or Discipline | Healthcare Administrators, Operations, Nursing, Nursing Research, Pharmacy |
Project Lead(s) | Tan Yuen Meng |
Project Member(s) | Tan Yen Yen |
Connect with this contributor!
Tan Yuen Meng - yuen_ming_tan@nuhs.edu.sg
Project Attachment
Aiming for Zero Inpatient Pharmacy (IP) Medication Supply Errors.pdf