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|Christina Yuen Ki Leung|
|The University of Hong Kong â Shenzhen Hospital (HKU-SZH), China|
|Keynote: J Pharma Care Health Sys|
|In China, medication incident reporting and management has recently started in healthcare settings. In HKU-SZH, a multi-disciplinary team including clinical pharmacists oversees the medication incident management. The healthcare staff is encouraged to report medication incidents including near-misses using the hospital approved reporting form. Serious medication incidents are investigated using root-cause-analysis. Every month, the clinical pharmacist attends the incident management team to discuss the medication incidents and the improvement actions. Every quarter, the clinical pharmacists are responsible to prepare the statistical incidents summary report which is then submitted to the Quality and Safety Management Committees. For serious or repetitive incidents, quality improvement measures are suggested to prevent recurrence of medication incidents. Examples of the improvement measures implemented are: â¢ Clinical Pharmacists prepare the quarterly medication safety newsletter to raise the awareness of the medication safety and to show the improvement actions that were implemented. â¢ Develop high alert drugs management policy and the drugs list. â¢ Incorporate patient drug allergy history and medication reconciliation template in electronic prescribing system. â¢ Change the dosage unit of insulin from âUâ to âunitâ and from IU to âinternational unitâ in the electronic prescribing system. â¢ Add patient weight (in kg) section in the electronic drug chart to aid the accurate calculation of dosage especially for children. â¢ Develop clinical guideline for some high risk drugs such as Fentanyl patch. â¢ Clinical pharmacists have prepared over 50 patient leaflets to enhance the optimisation of drugs use and patient safety. â¢ Additional patient counselling service for patients on warfarin on the ward. â¢ Involvement of clinical pharmacists in the out-patient clinic. E.g. Diabetic clinic. â¢ Deliver teaching sessions to the nurses and doctors. E.g. âSafe and effective use of insulinâ for nurses, and the âEffective medicine managementâ for newly joint doctors. For healthcare professionals to report medication incidents is a big step forward in risk management in China. A âno-blameâ culture is essential to encourage medication incident reporting. We learn from all the incidents reported to us and they guide us to develop improvement plans to further enhance medication safety.|
Christina Yuen Ki Leung completed two Bachelor degrees in England, Management Sciences degree followed by a Pharmacy degree. Following the registration as a Pharmacist in England, she worked in a number of teaching hospitals in London. After the completion of junior pharmacist training, she spent 12 years as Women’s and Children’s Pharmacist, mainly specialising in Paediatric ICU, Paediatric Liver, Obstetrics and Gynaecology. She published a number of articles including two articles relating to drugs use in paediatric liver diseases published in UK healthcare magazine. She is also a registered pharmacist in HK and she is currently working as the Senior Pharmacist (Clinical Pharmacy Service) at the HKU-SZH in China. She is also the Honorary Lecturer of the Department of Pharmacology and Pharmacy at the University of Hong Kong.
Email: [email protected]
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