Multifaceted approach to reduce duplicate therapy errors in the emergency department.

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Medication Error Reduction

Background:

• Medication errors represent a major cause of avoidable harm globally, with emergency departments (EDs) being particularly vulnerable due to high patient volumes and urgent care demands.
• Therapeutic duplication, defined as concurrent prescription of identical or pharmacologically equivalent agents, constituted 31% of medication errors at Changi General Hospital's ED between January 2019 and July 2022.
• These errors compromise patient safety, increase healthcare costs, and contribute to staff stress.

Purpose of the Study:

• To implement a quality improvement (QI) project aimed at reducing therapeutic duplication errors by 50% within three months post-intervention in the ED.
• To identify and address the root causes of medication errors in the ED setting.
• To establish sustainable strategies for maintaining reduced error rates.

Main Methods:

• A four-phase QI approach was employed from August 2022 to December 2023: problem identification (audit Jan 2019-Jul 2022), root cause analysis (RCA), intervention development and implementation, and sustainability planning.
• The initial audit identified therapeutic duplication as a significant medication error type.
• RCA pinpointed system knowledge deficits, IT process inadequacies, environmental factors, policy gaps, and care coordination issues as key contributors.

Main Results:

• The QI project successfully achieved its primary goal, reducing therapeutic duplication error rates by 50% post-intervention.
• Specific medication categories experienced complete elimination of therapeutic duplication errors.
• The interventions, stakeholder engagement, and ongoing audits contributed to sustained improvements in medication safety.

Conclusions:

• Targeted interventions, informed by a thorough root cause analysis, are effective in significantly reducing medication errors like therapeutic duplication in the ED.
• Active stakeholder engagement and a structured approach to QI are crucial for successful implementation and sustained improvements in patient safety.
• Continuous monitoring and adaptation of strategies are essential for maintaining a safer healthcare environment and preventing future medication errors.