Authors (including presenting author) :
Wong CW(1)(8),TAM S(1)(11),Leung C(1)(11),Cheng PL(1)(9),Wong TF(1)(2),Mok KW(1)(2), Luk J(1)(3),Lee MH(1)(4),CHAN S(1)(9),Szeto TL(1)(2),Chen J(1)(11),Leung CP(1)(8), Chan KC(1)(6),Chan KCJ(1)(5),Chan KC(1)(6),Lam CY(1)(2),Yu HY(1)(3),Yuen CK(1)(3), Lee L(1)(6),Chan A(1)(7),Leung YYJ(1)(2),Wong TW(1)(2),Wong WL(1)(2)
Affiliation :
(1)RTSKH Medication Safety Committee,(2)RTSKH Department of Medicine & Geriatrics, (3)RTSKH Department of A&E,(4)RTSKH Department of Surgery,(5)RTSKH Department of Orthopaedics & Traumatology,(6)PYNEH Department of Otorhinolaryngology, Head and Neck Surgery,(7)PYNEH/ RTSKH Department of Anaesthesiology,Perioperative and Pain Medicine,(8)RTSKH Nursing Services Division,(9)Intensive Care Unit,(10)Community Health Services,(11)Department of Pharmacy
Keyword 1: :
Medication Safety
Introduction :
Medication-related incidents were identified as the highest risk item in the 2025 Risk Register at Ruttonjee & Tang Shiu Kin Hospital (RTSKH). In response, the RTSKH Medication Safety Committee conducted a comprehensive review of all reported incidents in 2024 to identify root causes and contributing human and system factors. A bundled and integrated Continuous Quality Improvement (CQI) strategy was developed to strengthen the hospital’s medication safety framework through systematic, sustainable interventions.
Objectives :
To reduce medication-related incidents through a 360-degree CQI approach integrating system redesign, safety culture building, and competency-based training.
Methodology :
An integrated intervention was implemented across three key domains: 1.System Redesign - Applying Hazard Elimination & Engineering Control, Adrenaline 1:1000 was removed from general ward stock - Standardized Dangerous Drug (DD) labeling was introduced using consistent Tall-man lettering, font, and colour coding in DD cabinets and registers - A Smart Infusion Pump system was piloted in a general ward from June 2025, featuring a drug library with standardized concentrations, programmable upper and lower dose limits, and central monitoring to enhance the safety of high-alert medication infusions. 2. Safety Culture Building - A Medication Safety Forum, themed “The Paths to Medication Safety” engaged 99 multidisciplinary staff to share experiences and strengthen safety awareness. - A collaborative platform, “MedSafe Together,” was established to promote cross-disciplinary learning through quarterly, structured, case-based discussion among doctors, nurses, and pharmacists. - Continuous Medication Safety messaging was further reinforced through posters & safety slogans, to sustain staff engagement. 3. Simulation-Based Training and Competency Assessment - Specialty-specific, scenario-based simulation training on high-alert medications was conducted for nurses to strengthen the application of medication safety principles in real-life clinical situations. - The 2025 nurse graduate competency assessment incorporated scenario-based questions and return demonstrations covering safe handling of Dangerous Drugs, administration of PRN medications, and appropriate delegation of medication-related tasks.
Result & Outcome :
Compared with 2024, the total number of medication incidents decreased from 28 to 25 in 2025,representing a 11% reduction with notable declines in prescribing errors (67%) and administration errors (15%). A 360-degree, multidisciplinary CQI approach integrating system redesign, safety culture enhancement, and simulation-based competency training effectively reduced medication incidents and strengthened staff awareness of system vulnerabilities. This comprehensive and coordinated model demonstrates a sustainable and transferable strategy for improving medication safety through shared accountability, continuous learning, and system-level safeguards.
