Multifaceted approach to reduce duplicate therapy errors in the emergency department

Abstract

Medication errors continue to pose a significant risk to patient safety, accounting for half of the avoidable harm in healthcare systems around the world. In emergency departments (EDs), factors such as high patient loads and emergent nature of care increase the likelihood of such errors. An audit conducted at the ED of Changi General Hospital Singapore from January 2019 to July 2022 revealed that the duplicate therapy error comprised 31% of all reported medication errors. Therapeutic duplication occurs when the same or pharmacologically equivalent agents are prescribed concurrently to a patient. These errors not only jeopardise patient safety but also place additional strain on healthcare resources and lead to stress among the staff involved.This quality improvement (QI) project aims to reduce duplicate therapy error by 50% 3 months post-intervention at the ED. Beginning in August 2022 and continuing through December 2023, the project followed a structured approach comprising four phases: problem identification, identifying root causes, developing of targeted interventions and ensuring sustainability. Phase 1 involved an audit from January 2019 to July 2022 to determine the extent and types of medication errors in the ED. In phase 2, a root cause analysis (RCA) of the medication error identified key issues such as system knowledge deficits, inadequate IT processes, environment, policies and procedures and gaps in care coordination. Based on these findings, targeted interventions were developed and implemented in phase 3. Phase 4 focused on sustaining improvements through ongoing audits.The QI project successfully met its goal of reducing duplicate therapy error rates by 50% post-intervention. Additionally, it completely eliminated duplicate therapy errors in certain medication categories.In conclusion, through targeted interventions, active engagement of relevant stakeholders and ongoing efforts to sustain and enhance improvement, a safer healthcare environment can be achieved for patients.

Keywords: Continuous quality improvement; Medication safety; Quality improvement.