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Anbukkarasi D/O Sakadevan Naidu Zuhaida Binte Amir, Hwang Siew Wai, Oh Chee Chain
Reducing Incidence of Missed Supply of DOT Medications for Sunday and Public Holiday
INTRODUCTION
Patients diagnosed with TB have to undergo Directly Observed Therapy (DOT) program at Polyclinics. Registered Nurses (RNs) administer prescribed TB drugs and supply medication for patient to self-administer during Sundays and Public Holidays according to their treatment regime. Current processes: A self written reminder slip was clipped on to a standing chart to serve as a reminder for nurses to pack DOT medication for Sunday / Public Holiday (Figure 1).
METHODOLOGY A multi-disciplinary team was formed
Brainstorming session to share ideas and check possible gaps on current practices.
Engaging all Stakeholder to identify the possible cause using Cause and Effect Diagram through multi voting.
Voting Chart was used to identify the highest score / rank to prioritize the issues and finalize the outcome results.
Cause & Effect Analysis :( figure 2). 2 Key factors identified with highest score. (Figure. 3)
a. Current reminder used was not effective. b. The reminder was a temporary slip clipped
on to a standing chart.
Results
New Flip Chart. Figure. 4
Members brainstormed on the design of the new visual tool based on color, font, logo, day and treatment regime ( Figure. 4)
A pre & post implementation survey was conducted to investigate the effectiveness of the new Flip Chart. positive outcome results as shown below:
CONCLUSION No incidence of missed supply of DOT medication reported. The usage of New Flip Chart was introduced and implemented
across 9 SingHealth Polyclinics.
Sustainability Training for New Staff Regular feedback session Regular internal audit to ensure compliance
Intangible Benefits Enhanced Patient Safety Flip Chart act as a ‘ Safe Guard’ Prevent Human Error
Acknowledgement We would like to thank : Ms Stephanie Teo Swee Hong ( Chief Nurse), Ms Elaine Tan Siam King ( Assistant Director of Nursing) , Ms Tan Ai Meng ( Assistant Director of Nursing)
AIM To explore ways to reduce incidence of staff missed supply DOT medications to patients for Sunday and Public Holiday
Figure.1
INTERVENTION
Figure.3
0
1
2
3
4
5
6
7
8
Dull looking
High Activity room
Not attractive
Over look day of the week
Patient did not bring DOTfolder
Temporary Slip Note
Cause and Effect Vote Chart
3
8
5
2
7
Figure.2
Missed Supply of DOT Medications for
Sunday and Public Holiday
Failed to counter check with other staff
Nurse did not check system
Dull Looking
High turn over of DOT patient Overlook day
of the week
Too tired
Lengthy communication
with nurse Want to be served first
Late arrival For treatment
Rush nurse to serve medicine
Space constraint
Failed to counter checked with other staff
Unpleasant side effect
High activity room
Over crowding Distraction from incoming call
Font too small
Not attractive
Temporary slip note ENVIRONMENT
TOOL
Reminder Slip
PEOPLE POLICIES
Documentation Nurses
Patient
Treatment Room
Results on Pre and Post Implementation Survey
