IPSG 3 - Improve the safety of HAM

Question 1

Is there a list of HAM and LASA medications used in your clinical area/ward?

How often the list of LASA and HAM are reviewed?

Answer 1

HAM are reviewed?
-Annual reviews its own HAM list based on internal data, near misses, medication errors and SREs (to check the date of last reviewed)
-Reviewed annually by Medication
Safety Workgroup

Question 2

What does the “black”, “red” and tall letter on the panel means?

Answer 2

-Black on white = multiple strength
-Red on white = High alert medication
with single dose
-Red on black = High alert medication
with multiple dose
-Tall man letter = sound alike and look
alike medication

Question 3

Who is allowed to serve HAM?

Answer 3

HAM must be served and
counterchecked by another doctor, confirmed RN or unconfirmed RN who have undergone and passed the competency assessment in
administration of oral, IV and HAM.

Question 4

How do you report on CD wastage?

Answer 4

1. Report for CD
   Breakage/Wastage/loss of CD form (For expired or opened CD)
   -To return expired or near expiry CD (cannot be circulated)
   -If CD is opened, to retain the drug in the syringe together with the opened ampoule and return to pharmacy.
   -Ward/unit supervisor, pharmacist must be informed immediately.
   -Ward to raise CD wastage form and cost is charged to ward center.
   -CD wastage form is to be signed off by
   ANC and above.
   -Hand the completed form (duplicate) and any remains of the wastage to the pharmacist personally during office hour. Wastage that is not handed to pharmacist is to be included in the counting.
   -If ward supervisor is on leave, inform neighbouring ward/unit supervisor to help with the signing.
2. Pharmacy return voucher
   -To return CD <6 month of expiry date but still can be circulated to fast moving dept to pharmacy.
   -When the drug is expired, pharmacy will raise wastage form and absorb the cost.

Question 5

Loss or excess of CDs

Answer 5

1. Report to ward/unit supervisor and pharmacist immediately.
2. Conduct search.
3. Complete CD
   Breakage/Wastage/loss of CD form.
4. Police report must be made it the loss is unaccounted tor.
5. HAS will be notified by the pharmacist.

Question 5

Fentanyl Patch found missing from patient body

Answer 5

1. Conduct search
2. Inform staff including ESA to handover the patch to nurses if found
3. Dispose the patch as per disposal gui delines and document it if thepatch is found
4. Reassess pain score
5. Reassess pain score, inform doctor and ward/unit
   supervisor if the patch could not be found, document and raise PRISM

Question 6

Documentation of patient own CD

Answer 6

-Documentation patient’s name and
NRIC (in red ink) in CD Administration book
-Document the quantity received under
“Amount Received”
-Add the quantity to the “Total Balance”

Question 6

Handling of Patient’s Own CD

Answer 6

-Use of patient’s own CD during the hospital stay is not permitted
-Exception when medication are not available in the hospital formulary.
Advise patient/ family to bring own CD home and document in Special
Instructions Record after reviewed by doctor
-If patient’s relative is unable to bring home patient’s CD, keep patient’s CD in the CD cupboard separately from ward stock