Give Intravenous Morphine Bolus a BRAKE
Care Process & Redesign
National Healthcare Innovation and Productivity Medals
SingHealth
31 December 2022
To improve patient safety by reducing IV morphine bolus errors in A&E care by 50% using a Syringe Brake. Syringe Brake has improved safety and efficiency in A&E and inpatient wards; expanded to other institutions.
Year Submitted: 2022
Published Date: 31 December 2022
Tags: Care Process ＆ Redesign, Value Based Care, Risk Management, Adverse Outcome Reduction, Product Development, Prototyping Resources, Product Evaluation, Workflow Redesign, Clinical Practice Improvement
About this Content
Aims
To improve patient safety by reducing IV morphine bolus errors in A&E care by 50% using a Syringe Brake.
Background
Morphine administration errors due to manual processes increased risk of overdose and inefficiencies.
Methods
Developed and tested Syringe Brake to control dose delivery; integrated workflow and conducted training for adoption.
Results
Reduced error frequency significantly; achieved a 34.1-month error-free interval in A&E with increased safety and efficiency.
Conclusion
Syringe Brake has improved safety and efficiency in A&E and inpatient wards; expanded to other institutions.
Lessons Learnt
Co-design with stakeholders and phased implementation ensure high adoption and scalability.
Additional Information
Integrated into workflows at CGH, SGH, and SKH since 2018.
Keywords
IV Morphine, Medication Safety, Syringe Brake
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | SingHealth |
Organization(s) Involved | Changi General Hospital |
Platform(s) | National Healthcare Innovation and Productivity Medals |
Healthcare Professional Group(s) | Healthcare Administration, Medical, Pharmacy |
Applicable Specialty or Discipline | Pharmacology, Emergency Medicine |
Project Lead(s) | Yasmin Ng Yen Yen |
Project Member(s) | Sim Guek Gwee |
Connect with this contributor!
Yasmin Ng Yen Yen - yasmin_ng@cgh.com.sg
Project Attachment
C_677_CGH_NHIP_2022_Give_IV_Bolus_Morphine_Overdose_a_BRAKE.pdf