Authors (including presenting author) :
MIU HS(1), PAK CHH(1), CHUNG KYE(1)(2), WONG B(3), CHAN LO(4), LEUNG YS(1)(2)(3)(4)
Affiliation :
Department of Pharmacy (1)Hong Kong Buddhist Hospital, (2)Our Lady of Maryknoll Hospital, (3)Kwong Wah Hospital, (4)Queen Elizabeth Hospital
Keyword 2: :
medication safety
Keyword 5: :
dispensing safety
Introduction :
Medication safety involves practices to reduce medication errors. In pharmacies, achieving zero dispensing errors is challenging due to rising service volumes in Family Medicine Clinics (FMCs), increased case complexity from medical downloads, and limited dispensing/storage space. With these challenges and limitations, it is recognized that the input from frontline staff in form of a medication safety group would be valuable and effective.
Objectives :
To enhance medication safety in Kowloon Central Cluster Family Medicine Clinic (KCC FMC) Pharmacy by encouraging a speak up culture through a focus group approach
Methodology :
A focus group of 10 pharmacy staff from KCC FMCs with at least 5 years’ experience, facilitated by two experienced pharmacists, discussed medication safety using a fish-bone diagram and a "man-machine-material-method-environment" analysis as the framework. Supervisors of group members were excluded to encourage participants to speak up. The focus group aimed to engage pharmacy staff in enhancing medication safety by identifying error contributors, gathering feedback on current systems, and collecting improvement suggestions. It also sought to demonstrate the organization’s commitment to addressing medication incidents constructively. The aim, scope and ground rules of the focus group were briefed to members before the meeting.
Result & Outcome :
The focus group generated practical recommendations to enhance medication safety, including (1) regular peer reviews, (2) implementing label triage and the Auxiliary Label Printing System (ALPS), (3) adding alerts in the Pharmacy Management System (PMS) for high-risk drug pairs, (4) eliminating redundant pre-check steps, and assigning support staff to minimize distractions. A follow-up survey revealed that 83% of participants found the session highly effective in improving medication safety awareness, fostering knowledge exchange, and promoting best practices. Notably, these initiatives were associated with a significant reduction in dispensing errors (May-2023 to Apr-2024 vs Jul-2024 to Jun-2025), with reported incidents in KCC FMCs dropping by more than 50% post-implementation in 2024. The outcomes highlight the value of collaborative discussions in driving systemic improvements and reinforcing a safety-oriented culture in pharmacy operations. A well-facilitated focus group creates a safe and non-judgmental environment where participants feel comfortable sharing their experiences, concerns, and ideas. This fosters a culture of accountability and collaboration, where staff’s perspectives are valued, which has a positive impact on staff adherence to guidelines and behavioral change. By fostering openness, providing a platform for participants to speak out freely, and capturing frontline insights, medication safety focus groups play a vital role in identifying and addressing medication-related challenges. In our study, it is evident that the medication safety group in pharmacy contributes to the observed significant decrease in incidents.
