Trying to make medication process safe
I refer to your report dated March 24 headlined, 'Child overdoses blamed on hospital staff'.
My title is the President of the Society of Hospital Pharmacists of Hong Kong and not the Society of Hospital Pharmacy Workers. And since the report only focused on a small facet of the problem of medication error, I would like to supplement your readers on this important issue.
Since a wrong medication was given to two babies in the Prince of Wales Hospital in 1991, health care workers such as pharmacists, dispensers, doctors and nurses have been concerned about the safety of the medication process in hospitals.
Both private and public hospitals have become more alert to the potential problem and tried to do something about it.
The Society of Hospital Pharmacists of Hong Kong has organised seminars and workshops and even invited overseas experts to talk to local practitioners on the subject.
Likewise, the Hospital Authority has set up a special working group to examine the overall procedures of medication practices in public hospitals. A Medication Incidents Reporting Programme (MIRP) has been started to collect statistics and examine the nature of medication errors occurring in hospitals. While there have not been any official figures on medication error before, quarterly figures are now available since the commencement of the MIRP in 1994.
The MIRP is not a fault-finding nor finger-pointing exercise, but a tool in gathering information on circumstances under which mistakes could be made. It has served its purpose. During the past few years, all public hospitals have installed proper drug trolleys on the wards to improve the storage conditions and prevent mix-ups of medications. All pharmacies are computerised to improve the legibility of medication labelling and to include vital information on the labels. Some hospitals have implemented a Direct Medication Order Entry system whereby doctors order their medications into a computer, the information of which would be transmitted to the computer in the pharmacy. This eliminates the risk of error due to transcription on paper.
Clinical pharmacists are beginning to work closely with doctors and patients to improve medication safety. Bulletins, workshops and lectures are frequently organised for health care professionals to alert them against common pitfalls in the medication process. And these initiatives implemented to safeguard our patients, could not have started without information gathered from a voluntary medication incidents reporting programme.
When one looks at the figures of medication incidents, it is not difficult to see that most of the incidents did not involve patients. Many potential errors were stopped before reaching the patient. The fact that the errors are still reported reflects the determination of health care professionals to face the problem and learn from potential mistakes. Laying the blame on hospital staff - as your headline of the report suggests - is never the intention of those involved. Fault-finding from figures alone does a disservice to the entire campaign for improvement of medication safety. Figures should be and have been used in a more positive way that could benefit the patient.
When I attended the World Pharmacy Congress in Israel last September, I had an opportunity to exchange views with overseas pharmacists who were also interested in medication safety. We noted that our figures were comparable with others. Our effort on medication safety in Hong Kong was commended by experts in advanced countries.
When we look at figures alone, we must remember that the medication process is a complicated matter. Just as there are going to be traffic accidents every day, there are going to be medication incidents - large and small. To health care professionals, even a single error involving a patient is not acceptable. And that is why we have been doing so much in the past few years in an attempt to make the medication process safe for our patients.
MICHAEL LING President The Society of Hospital Pharmacists of Hong Kong