Authors (including presenting author) :
LI HY (1), KO HK (1), WONG TT (1), PANG HSI (1)
Affiliation :
(1) Department of Medicine and Geriatrics, Ruttonjee & Tang Shiu Kin Hospitals
Keyword 1: :
Medication Safety
Keyword 2: :
wrong frequency or scheduling
Introduction :
Medication incident causes a significant risk to patient safety, leading to adverse drug events and negatively impact on health outcomes. From 2023 to 2025, 35 medication incidents were reported in RTSKH. 19 of them were injection related and more than half were defined as wrong frequency. In fact, with the complexity of medication regimen, drugs like erythropoietin (EPO) and osteoporosis injection, are given at a specific week or month interval. Caution on prescription and administration processes are crucial to avoid from omission or extra dose. However, there are various platforms for retrieving injection records from different healthcare settings. Those scattering information can definitely contribute to errors. An initiative on an injection reminder label is introduced by using PDCA cycle in an acute geriatric ward setting to eliminate any possible risk.
Objectives :
-Standardize checking system on the specific injection regimen among different healthcare settings -Allow easy acknowledgement and documentation on treatment verification -Set up patient-based record for close loop communication during hospitalization -Eliminate risk on wrong frequency of specific injection regimen
Methodology :
PLAN Identify problem: -Non-compliance checking mechanism on medication scheduling -Lack of familiarity with Electronic Injection Record (EIR) -Unawareness of injection record other than electronic documentation -Unclear documentation on the last dose administration by various care provider DO In the end of August 2025, a ward meeting was hold to review on the injection schedule checking process with all frontline nurses to ensure proper verification on the last dose injection from all stakeholders. Also, similar medication incident was shared. Secondly, a tracking reminder label was designed to summarize those verified information. The updated enhancement on EIR and the new workflow on the management of those specific injection regimen was introduced to all nursing staff through two identical training sessions. On-going behavioural observation on the workflow and usage of reminder label would be performed to ensure the sustainability of safe practice.
Result & Outcome :
Safe practice on drug scheduling of specific injection regimen and related medication incident CHECK A retrospective audit on the compliance of reminder label implementation was performed. There were total 37 IPMOE prescriptions on EPO, Vitamin B12 and osteoporosis injection during September to November 2025. The utilization rate of reminder label was 100% and all cases indicated the source of verified last dose information. Moreover, scheduling on all prescription lines were correct and the documentation on the updated injection date was clearly found on nursing discharge summary. By collecting staff feedback, they showed satisfaction on the clarity and standardization of information from the reminder label. All of them agreed an increase in the awareness on the safe practices toward these specific injection regimens. ACT The workflow on the management of specific injection regimen was adopted to in-house training on medication safety. This preventive measure was shared at departmental meeting. Incident reporting was closely monitored and there was nil similar incident in 3Q25
