Tsang, L., Tsang, W., Yiu, K., Tang, S., Sham, S. (2017). The Use of PDSA Cycle to Evaluate a “Pointing and Calling” Implementation in Reducing High Alert Medication Administration Incident in United Christian Hospital. Journal of Patient Safety & Quality Improvement, 5(3), 0-0. doi: 10.22038/psj.2017.9043
Lap Fung Tsang; Wai Yi Tsang; Ka Chun Yiu; Siu Keung Tang; So Yuen Alice Sham. "The Use of PDSA Cycle to Evaluate a “Pointing and Calling” Implementation in Reducing High Alert Medication Administration Incident in United Christian Hospital". Journal of Patient Safety & Quality Improvement, 5, 3, 2017, 0-0. doi: 10.22038/psj.2017.9043
Tsang, L., Tsang, W., Yiu, K., Tang, S., Sham, S. (2017). 'The Use of PDSA Cycle to Evaluate a “Pointing and Calling” Implementation in Reducing High Alert Medication Administration Incident in United Christian Hospital', Journal of Patient Safety & Quality Improvement, 5(3), pp. 0-0. doi: 10.22038/psj.2017.9043
Tsang, L., Tsang, W., Yiu, K., Tang, S., Sham, S. The Use of PDSA Cycle to Evaluate a “Pointing and Calling” Implementation in Reducing High Alert Medication Administration Incident in United Christian Hospital. Journal of Patient Safety & Quality Improvement, 2017; 5(3): 0-0. doi: 10.22038/psj.2017.9043
The Use of PDSA Cycle to Evaluate a “Pointing and Calling” Implementation in Reducing High Alert Medication Administration Incident in United Christian Hospital
1Nursing Services Division, United Christian Hospital, Hong Kong Special Administrative Region, China
2Department of Medicine & Geriatrics, United Christian Hospital, Hong Kong Special Administrative Region, China
Abstract
Introduction: High alert medication administration incidents using infusion and syringe device leading to severe consequence and its contributory factors were highly associated with human errors. Materials and Methods: This study was to adopt a Plan-Do-Study-Act cycle to monitor the Pointing and Calling (P&C) implementation in United Christian Hospital in Hong Kong. A workgroup was formed to study how P&C can be applied in the high alert medication administration using syringe or infusion device. A series of promulgations and strategies were implemented to increase the probability of its success and sustainability. A pre-and-post evaluation was carried out to monitor the incident rate related to high alert medication using infusion and syringe device. Results: Over 100 briefing sessions were conducted in wards and there were 145 senior managements, ward managers and advanced practice nurses completed the training and assessment. A total of 217 questionnaires using a 6-point Likert scale were returned from twenty-one wards and had a response rate of 26.53%. An audit was performed to obtain 98.1% to 100% of compliance rate of using the P&C for checking. Since June 2016, the incident rate due to wrong device setting decreased from 0.21 to 0.13 after the P&C implementation. Conclusion: The P&C is a simple method to facilitate nurses checking high alert medication meticulously. There is room for improvement to address other areas that were not identified. Counter measures were proposed to strengthen the compliance with the P&C.
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