Improving Patient Safety by Reducing Pharmacy Near Miss
Care Process & Redesign
Singapore Healthcare Management Congress
SingHealth
31 December 2021
To reduce the number of pharmacy near misses due to wrong quantity and wrong strength by 20%. PDSA cycles provide a structured method to reduce pharmacy near misses effectively.
Year Submitted: 2021
Published Date: 31 December 2021
Tags: Care Process ＆ Redesign, Quality Improvement, Clinical Practice Improvement, Value Based Care, Safe Care, Adherence Rate, Risk Management, Preventive Approach, International Patient Safety Goals
About this Content
Aims
To reduce the number of pharmacy near misses due to wrong quantity and wrong strength by 20%.
Background
Errors in quantity and strength of medications are among the most common and preventable near misses in pharmacies.
Methods
Conducted surveys, Pareto analysis, and Ishikawa diagrams to identify root causes. Implemented two PDSA cycles targeting errors with visual aids and reinforced processes.
Results
Wrong quantity errors reduced by 32%; wrong strength errors by 29%. Metformin and Atorvastatin errors reduced to zero.
Conclusion
PDSA cycles provide a structured method to reduce pharmacy near misses effectively.
Lessons Learnt
Simplicity and minimal workflow disruption are essential for effective interventions.
Additional Information
SHM 2021 Quality Improvement Award.
Keywords
Pharmacy Near Miss, Medication Safety, Workflow Redesign
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | SingHealth |
Organization(s) Involved | SingHealth Polyclinics |
Platform(s) | Singapore Healthcare Management Congress |
Healthcare Professional Group(s) | Pharmacy |
Applicable Specialty or Discipline | Pharmacology |
Project Lead(s) | Choy YK |
Project Member(s) | Lee TY |
Connect with this contributor!
Choy YK - singaporehealthcaremanagement@singhealth.com.sg
Project Attachment
49_NTFGH_NUHS_NHIP_2020_Reduction_of_No_Show_Rate_in_Sleep_Lab_combine.pdf