Authors: (including presenting author): :
LEE KSP(1)(3), LI MN(1)(4), KWOK YT(1)(2), SHING LY(1)(2), HUI TP(1)(2), NG MY(1)
Affiliation: :
(1)Medication Safety Committee, NTWC, (2) Quality & Safety Division, NTWC,(3) Department of Pharmacy, NTWC,(4) Nursing Services Division, NTWC
Keyword 1: :
Standardization
Keyword 2: :
Dangerous Drug Storage Management
Introduction: :
Dangerous Drugs (DD) management requires strict adherence to safety protocols, yet physical storage environments often vary across units, creating latent safety risks. During the Medication Safety Walk Round conducted by NTWC Q&S and Cluster Medication Safety Committee (MSC) in May 2024, it revealed significant inconsistencies in DD storage containers and cabinet designs across clinical wards, which may increase the risk of selection errors due to non-standardized layouts and labelling. To proactively mitigate these risks before they led to patient harm, NTWC initiated a comprehensive program to standardise DD storage and stock management principles across the cluster.
Objectives: :
To standardise DD storage containers, cabinets, and labels to reduce cognitive load on frontline staff.; To develop working principles for DD management; To proactively identify and eliminate inconsistent storage practices that may contribute to medication errors.
Methodology: :
A multidisciplinary workgroup was formed in August 2024, comprising representatives from Q&S, NSD, Pharmacy, and clinical wards representatives. Between August 2024 and August 2025, the workgroup formulated the principles for DD storage, standardised two sets of containers and DD labels (with Tall Man lettering and labelled high alert medications) and developed a standardised dimension for DD cabinets to ensure adequate capactity for DD storage. The standardized model was piloted in TMH wards (M&G, O&T, Surg, A&E, O&G) in May 2025, followed by a progressive rollout to remaining clinical wards in Nov 2025.
Result & Outcome: :
The standardization of DD storage yielded positive frontline feedback, with over 90% of pilot wards reported improved organization and reduced error risks. Following this success, the standardized containers and labels were progressively rolled out to the remaining clinical wards in TMH in Nov 2025, with a final evaluation currently in progress. During the implementation process, it identified that certain DD cabinets were physically incapable of accommodating the new safety standards due to size limitations. A coordinated plan is in place for the coming year to liaise with the Facilities Management Department to replace these inadequate cabinets. By moving from reactive error correction to proactive system design, this initiative has minimized manual handling errors and strengthened the safety culture. The project is now expanding to other cluster hospitals (POH, TSWH, CPH, SLH), ensuring that standardized safety barriers are in place throughout NTWC.
