Redesign Medication Picking Process to Improve Safety
Care Process & Redesign
Singapore Healthcare Management Congress
SingHealth
11 February 2026
1) Redesign the medication picking process to enhance accuracy, reduce errors, improve overall operational efficiency and. The incorporation of human factor elements into medication gondola naming and medication bin label design, along with process.
Year Submitted: 2025
Published Date: 11 February 2026
Tags: Care Process ＆ Redesign, Workflow Redesign, Quality Improvement, Value Based Care, Safe Care
About this Content
Aims
1) Redesign the medication picking process to enhance accuracy, reduce errors, improve overall operational efficiency and staff satisfaction. 2) Reduce the number of picking-related medication incidents from 15 to 10 per month (30%) at Block 4 Level 1 Pharmacy from August 2023 to July 2024.
Background
Block 4 Level 1 Pharmacy dispenses an average of 1750 items daily. The supply process involves picking of medication and consumables based on bin locations indicated on medication labels. From August 2022 to July 2023, the Pharmacy recorded a monthly average of 15 medication incidents from inaccurate picking. These events resulted in extensive investigations where staff interviews were conducted, inventory records were checked, CCTV footages were played, patients were contacted for rectification of errors and subsequent service recoveries which were resource intense.
Methods
A Cause-and-Effect Diagram was employed to identify potential root causes, and a Pareto Chart was utilised to determine the vital few root causes. Solutions were brainstormed using Tree Diagrams and Prioritisation Matrix. During solutioning, a human factors expert was consulted to provide inputs on medication bin label design. Medication bin location was printed on larger font size on colour coded labels and the HDB naming convention was adopted to help staff accurately identify the medication bin locations. Staff feedback were sought to continuously refine the medication bin label design.
Results
Following the implementation of the solutions in Aug 2023, Block 4 Level 1 Pharmacy reported a 43% reduction in medication picking incidents, from 15 to 8.5 incidents per month between Aug 23 to Jul 24. The number of medication picking incidents reported further reduced to 5 per month from Aug 24 to Apr 25. Staff reported better experience reading the new medication bin label compared to the previous version.
Conclusion
The incorporation of human factor elements into medication gondola naming and medication bin label design, along with process standardisation, has successfully reduced picking errors at Block 4 Level 1 Pharmacy.
Lessons Learnt
The incorporation of human factor elements into medication gondola naming and medication bin label design, along with process standardisation, has successfully reduced picking errors at Block 4 Level 1 Pharmacy. The positive outcomes from this project have led to implementation of this safety initiative at other pharmacy locations within Singapore General Hospital.
Additional Information
Annual time savings (rectify near misses): 1080 mins. Annual cost savings (rectify near misses): $518.40. Annual cost avoidance (medication errors): $112,230.00.
This project was accorded the Merit Award for Operations Category at SHMC 2025.
Keywords
Medication Labelling, Medication Bin Location, Safety Initiative
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | SingHealth |
Organization(s) Involved | Singapore General Hospital |
Platform(s) | Singapore Healthcare Management Congress |
Healthcare Professional Group(s) | Pharmacy |
Applicable Specialty or Discipline | Pharmacy |
Project Lead(s) | Yeo Li Hsuen |
Project Member(s) | Pan Yongyu |
Connect with this contributor!
Singapore Healthcare Management Conference (SHMC) Secretariat - singaporehealthcaremanagement@singhealth.com.sg
Project Attachment
1129_SGH_SHM 2025_Redesign Medication Picking Process to Improve Safety.pdf