Authors: (including presenting author): :
Chow SYP, Wong KY, Leung SK
Affiliation: :
Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital
Keyword 2: :
5S methodology
Introduction: :
Medication administration in the NICU is high risk due to small dosing margins, complex calculations, and multiple concurrent infusions. Clear, accurate labelling of all central line and intravenous infusions is essential to prevent errors. An internal review found infusion labels were dispersed and inconsistently organized, causing delays in medication preparation and potential selection of incorrect labels. To address these risks and streamline workflow, we adopt 5S methodology to standardize label availability via a dedicated, mobile label trolley with clearly categorized compartments in order to enhance infusion safety.
Objectives: :
1. Reduce 50% mean preparation time of medication infusion label. 2. 100% staff are trained and updated on the workflow of use and system sustainable of the new label trolley. 3. No incidence of label shortage
Methodology: :
A multidisciplinary workgroup included NICU nurse consultant, managers, APN was formed to identify and quantify all types of medication infusion labels used within the unit. A proposal for a label trolley was designed, specifying on the layout of storage rack and compartment size, and labelling categories. The proposal endorsed the department management team. A project was launched for 2-month period. The drug label trolley was set up in July 2025 and introduced to all NICU staff. Staff were educated on the use and maintenance protocol of the trolley. 10 nurses were recruited by convenience sampling for time measurement of preparation time of medication infusion label by before and after the project. . Nurses were instructed to prepare the infusion label specified inside each opaque envelope and preparation time of infusion label is measured. Procedure of label preparation included: 1. Perform independent double check of treatment against medication administration record and resuscitation chart by 2 nurses. 2. Obtain appropriate label from the medical trolley(pre-intervention) or infusion label trolley(post-intervention) 3. Complete the information as stated on the infusion label and signed by 2 nurses
Result & Outcome: :
The implementation of a dedicated label trolley significantly improved the efficiency of medication infusion label preparation in NICU. The mean preparation time was reduced by 2.28 minutes (60%), from 3.82 minutes to 1.52 minutes (p=0.003). This statistically significant reduction was accompanied by decreased variability, indicating a more reliable and standardized workflow. The findings suggest that the intervention not only saved time but also likely reduced cognitive load, thereby supporting enhanced medication safety.
