Reduce Recormon Dispensing Errors at Outpatient Pharmacy (OP) Level 2
Care Continuum
Care Process & Redesign
National University Health System Quality Improvement
National University Health System
To reduce Recormon dispensing errors to zero and maintaining it there, at Level 2 Outpatient Pharmacy, and sustain this from.
Year Submitted: 2025
Published Date:
Tags: Care Continuum, Outpatient Care, Operational Management, Inventory Management, Risk Management, Adverse Outcome Reduction, Value Based Care, Safe Care, Care Process ＆ Redesign
About this Content
Aims
To reduce Recormon dispensing errors to zero and maintaining it there, at Level 2 Outpatient Pharmacy, and sustain this from Apr 2024 to Jul 2025.
Background
In January 2024, three separate incidents occurred where patients were incorrectly dispensed Recormon 4000 IU instead of the prescribed Recormon 2000 IU at Level 2 Outpatient Pharmacy. The recurrence of this specific error within a short timeframe suggests a systemic issue in the medication packing process for Recormon at this location. This problem needs to be addressed urgently to prevent further incidents, ensure patient safety, and maintain the hospital's high standards of care and reputation.
Methods
Root cause analysis identifying people, equipment, distraction, and process factors, PDSA cycles with three main interventions: installation of pop-up signages in front of Recormon bins to alert packers, improved communication with team through department meetings and incident sharing, and increased visibility by moving Recormon 2000 IU bin to front of fridge. Continuous engagement of staff on proper packing procedures and regular sharing of incidents and near misses during department meetings.
Results
Achieved zero Recormon dispensing errors from February 2024 onwards and sustained through July 2025
Signages were very effective in alerting pharmacy staff to check and pack the correct strength of Recormon
Staff provided positive feedback that the bin is more visible and easier to access when packing
Communications made to the team were effective in helping team become more compliant to existing packing workflows
Sustained zero errors for 18 consecutive months (February 2024 to July 2025)
Keywords
Recormon dispensing errors, medication safety, look-alike drugs, signage, outpatient pharmacy, packing
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, Pharmacy |
Applicable Specialty or Discipline | Healthcare Administrators, Operations, Pharmacy |
Project Lead(s) | Jenny Lee |
Project Member(s) | Nur Hazirah Sanusi |
Connect with this contributor!
Jenny Lee - lee_jenny_man_sze@nuhs.edu.sg
Project Attachment
Reduce Recormon dispensing errors at outpatient pharmacy (OP) level 2.pdf