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5PSQ-111 Improving patient safety and quality assurance through multidisciplinary clinical audits
  1. P Polidori,
  2. E Di Martino
  1. IRCCS ISMETT, Clinical Pharmacy, Palermo, Italy


Background Our Institute has been accredited with Joint Commission International (JCI) status since 2009.

Purpose The purpose of this study is to ensure the compliance with JCI standards and the statements of the European Association of Hospital Pharmacists (EAHP), in order to identify the risk factors inherent in daily activities of healthcare professionals (HPs) and prevent/reduce the incidence of errors in clinical practice.

Material and methods Clinical audits were conducted by multidisciplinary groups (HPs, pharmacists, quality responsibles etc. ). The audit was carried out in 5 days (5 to 9 June 2017) in seven wards, eight services and one outpatient clinic. The Clinical Pharmacy Service provided a checklist for ‘Medication Management Utilisation/International Patient Safety Goal 3’, focused on High-Alert Medications (HAMs) and Look-Alike/Sound-Alike (LASA) medications safety and EAHP statements. Medication management supply chain and departmental medications were checked.

Results A total of 100 HPs (including 21 physicians, 62 nurses, 10 pharmacists, six pharmacy technicians and one physiotherapist) were interviewed. From the interviews, it emerged that all staff were well informed on the correct control systems for HAMs administration. However, a critical finding was that 71% (44/62) of the nurses did not remember all HAMs requiring the double-check process (chemotherapy and paediatric drugs, insulin for continuous infusion, potassium chloride preparations, heparin and bupivacaine). In fact, only 12% (7/62) of nurses performed a double-check in the electronic medical record. From data analysis of HAMs management, compliance with storage and labelling standards has emerged. In six out of seven units, HAMs and LASA lists were present and both types of medications were kept separate. As regards the general status of departmental medications, compliance with their correct storage was found in 96% (15/16) of the wards. Refrigerator temperatures were documented in 63% (10/16) of the wards inspected and 90% of them were in compliance with standards. Opened multi-dose medications were present in 31% (5/16) of the wards, however, although their date of opening was correctly reported, the expiration date was wrong.

Conclusion The audit activity highlighted the ongoing commitment of the Institute for the improvement of performance in the use of medications. Continuing training and quality improvement plans for non-compliance standards and statements will be conducted.

References and/or Acknowledgements 1. JCI Standard2015.

No conflict of interest

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