Improving the quality of care in Hong Kong

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 Introduction
The annual report on sentinel and serious untoward events published by the Hong
Kong Hospital Authority in January 2021 revealed that medication errors were the most
common type of serious untoward event reported in public hospitals in Hong Kong. The
report highlighted the need for improved medication management systems and a culture of
safety and reporting to reduce the incidence of medication errors. Medication errors are a
significant issue in healthcare that can have serious consequences for patients, including
harm and even death. As such, there is a need to address this issue and improve the quality
of care provided to patients. This essay will explore the issue of medication errors in Hong
Kong's public hospitals and examine how clinical governance strategies can be used to
address this issue. Clinical governance refers to the systems and processes in place to
ensure that healthcare services are provided safely, effectively, and efficiently. By applying
relevant frameworks, this essay will examine how clinical governance strategies can be used
to reduce the incidence of medication errors in hospitals, promote patient safety, and
enhance patient outcomes.
Specifically, this essay will examine the role of clinical guidelines and protocols in
medication management, the importance of communication and collaboration among
healthcare professionals in preventing medication errors, and the use of audits and
monitoring systems to identify and address areas for improvement in medication
management. By exploring these topics and applying relevant frameworks, this essay aims
to demonstrate how clinical governance strategies can be used to improve the quality of care
provided to patients in Hong Kong's public hospitals and reduce the incidence of medication
errors. Ultimately, the goal is to promote patient safety and enhance patient outcomes in the
provision of healthcare services in Hong Kong.
Medication errors in relation to quality care provision in Hong Kong
Medication errors are a significant problem in Hong Kong healthcare, with the
potential to cause harm to patients and increase healthcare costs. Several factors contribute
to the occurrence of medication errors, including lack of communication among healthcare
professionals, lack of knowledge and training, and system-related issues such as inadequate
technology and work overload. One of the major issues contributing to medication errors in
Hong Kong is the lack of a standardized medication ordering system. In many cases,
different physicians prescribe medications in different formats, leading to confusion and
errors in medication administration (Fu et al., 2021). Moreover, handwritten orders can be
illegible, leading to misinterpretation by pharmacists and nurses. This can result in patients
receiving the wrong medication or the wrong dosage.
Additionally, the use of abbreviations and symbols can contribute to medication
errors. Abbreviations and symbols used in medication orders can be ambiguous and may
have different meanings for different healthcare professionals. For instance, "u" (meaning
unit) can be misinterpreted as "0" (meaning zero) or "4" (meaning four). This can lead to
incorrect dosing and administration of medications. Another issue is the lack of medication
reconciliation, which refers to the process of verifying and reconciling a patient's medication
list during transitions of care (West and Coia, 2019). Medication reconciliation is essential to
prevent errors that occur when a patient's medications are not accurately documented or
updated, which can lead to duplicate therapy, omissions, or drug interactions.
Moreover, the use of high-alert medications, such as anticoagulants and insulin, can
also contribute to medication errors. These medications have a narrow therapeutic index,
and small errors in dosage or administration can lead to serious adverse events. Lack of
knowledge and training on these medications and their administration can increase the risk
of medication errors (Jones et al., 2021). Furthermore, inadequate communication between
healthcare professionals is also a significant issue leading to medication errors. Healthcare
professionals often work in silos, and information is not effectively shared between different
departments. This can lead to medication discrepancies and errors in medication
administration. For example, a physician may prescribe a medication, but the pharmacist
may not be aware of the patient's other medications, resulting in a drug interaction.
Lack of knowledge and training is another factor contributing to medication errors.
Medication errors can occur when healthcare professionals do not have a thorough
understanding of medication safety or are not adequately trained on new medications or
medication administration procedures (Gottwald and Lansdown, 2021). Additionally,
language barriers and cultural differences can pose challenges to effective communication
and understanding of medication safety practices. Finally, system-related issues such as
inadequate technology and work overload can also contribute to medication errors.
Healthcare professionals may be required to use multiple electronic systems to access
patient information and medication orders, leading to confusion and errors. Work overload
can also lead to fatigue and stress, increasing the risk of medication errors.
Theoretical frameworks used to address quality care issues and increase potential for
change
Theoretical frameworks are essential in addressing quality care issues and increasing
the potential for change in healthcare systems. One of the commonly used frameworks is the
Donabedian model, which emphasizes the importance of evaluating healthcare quality based
on three main components: structure, process, and outcome (West and Coia, 2019). This
framework considers the physical, organizational, and human resources required to deliver
care (structure), the activities carried out to deliver care (process), and the effects of care on
patient health and well-being (outcome).
Another commonly used framework is the Institute for Healthcare Improvement's (IHI)
Model for Improvement, which involves three main questions: What are we trying to
accomplish? How will we know that a change is an improvement? What changes can we
make that will result in improvement? (Kaba and Öztürk, 2022). The IHI model emphasizes
the importance of setting clear goals and measures, testing and implementing changes on a
small scale, and continuously monitoring and evaluating outcomes.
The Plan-Do-Study-Act (PDSA) cycle is another framework commonly used in
healthcare quality improvement initiatives. It involves four main steps: planning a change
(Plan), implementing the change on a small scale (Do), observing and evaluating the results
(Study), and making adjustments based on the results (Act). This framework emphasizes the
importance of continuous evaluation and adjustment to achieve sustained improvement.
The Six Sigma framework is a data-driven approach to quality improvement that
emphasizes the importance of reducing variability in processes to achieve consistent and
predictable results. This framework involves a five-phase approach: Define, Measure,
Analyze, Improve, and Control (DMAIC). It emphasizes the importance of data analysis and
using statistical methods to identify and address sources of variability.
Application
Donabedian model: This framework emphasizes the importance of evaluating
healthcare quality based on three main components: structure, process, and outcome. In the
case of medication errors, the structure component would involve evaluating the physical,
organizational, and human resources required to deliver safe and effective medication
administration. This could include evaluating the availability and accessibility of medications,
the training and education of healthcare providers, and the availability of supportive
technology and equipment.
 The process component of the Donabedian model would involve evaluating the
activities carried out to deliver safe and effective medication administration. This could
include evaluating the medication ordering, preparation, and administration process, as well
as the monitoring and evaluation of medication use (Kaba and Öztürk, 2022). The outcome
component of the Donabedian model would involve evaluating the effects of medication use
on patient health and well-being. This could include evaluating the incidence and severity of
medication errors, as well as the impact of medication errors on patient outcomes.
The IHI Model for Improvement: This framework involves three main questions:
What are we trying to accomplish? How will we know that a change is an improvement?
What changes can we make that will result in improvement? In the case of medication errors,
the IHI model would involve setting clear goals for reducing the incidence and severity of
medication errors, as well as defining measures to evaluate progress towards these goals.
Changes that could be made to improve medication safety in Hong Kong could include
implementing technology solutions to reduce the risk of medication errors, such as
computerized provider order entry (CPOE) systems, barcode medication administration
systems, and automated dispensing cabinets. Other changes could include enhancing
healthcare provider education and training on safe medication administration practices and
implementing standard medication order sets to reduce the risk of errors.
The Plan-Do-Study-Act (PDSA) cycle: This framework involves four main steps:
planning a change (Plan), implementing the change on a small scale (Do), observing and
evaluating the results (Study), and making adjustments based on the results (Act). In the
case of medication errors, the PDSA cycle could involve testing small changes in medication
administration processes, such as implementing a new medication order verification process
or providing additional education and training to healthcare providers on medication safety.
By testing small changes on a small scale and continuously evaluating and adjusting the
approach, healthcare providers can identify and implement effective solutions to reduce the
risk of medication errors (West and Coia, 2019).
The Six Sigma framework: This framework is a data-driven approach to quality
improvement that emphasizes the importance of reducing variability in processes to achieve
consistent and predictable results (Ghavamabad et al., 2021). This framework involves a
five-phase approach: Define, Measure, Analyze, Improve, and Control (DMAIC). In the case
of medication errors in Hong Kong, the Six Sigma framework could involve defining the
problem of medication errors, measuring the incidence and severity of errors, analyzing the
root causes of errors, implementing changes to improve medication safety, and controlling
the process to ensure sustained improvement. Changes that could be implemented to
improve medication safety in Hong Kong could include implementing standardized
medication administration procedures, improving communication between healthcare
providers, and increasing the use of technology solutions to reduce the risk of errors.
Clinical governance strategies
One of the clinical governance strategies employed in Hong Kong is the use of
performance indicators to monitor and evaluate the quality of care provided by healthcare
organizations (Macfarlane, 2019). Performance indicators are measurements that reflect the
quality of care and the effectiveness of processes and systems used by healthcare
organizations. In Hong Kong, the Hospital Authority has implemented a set of performance
indicators that focus on the delivery of safe and effective care. These performance indicators
include clinical outcomes, patient satisfaction, and compliance with regulatory requirements.
By monitoring and evaluating these performance indicators, healthcare organizations in
Hong Kong can identify areas that need improvement and develop strategies to address
them (Gottwald and Lansdown, 2021).
Another clinical governance strategy used in Hong Kong is the implementation of
clinical practice guidelines (CPGs). CPGs are evidence-based recommendations that guide
healthcare professionals in the delivery of care. In Hong Kong, the Hospital Authority has
developed and implemented a set of CPGs to ensure that healthcare professionals deliver
safe and effective care to patients. These CPGs cover a wide range of clinical conditions and
procedures and are regularly reviewed and updated to reflect the latest evidence.
A third clinical governance strategy employed in Hong Kong is the use of clinical audit
to evaluate the quality of care provided by healthcare organizations. Clinical audit is a
process that involves reviewing patient records to assess the quality of care provided by
healthcare professionals. In Hong Kong, the Hospital Authority has implemented a
comprehensive clinical audit program that covers all aspects of clinical care. By conducting
regular clinical audits, healthcare organizations in Hong Kong can identify areas that need
improvement and develop strategies to address them.
Finally, another clinical governance strategy used in Hong Kong is the
implementation of a comprehensive risk management program. Risk management is a
process that involves identifying, assessing, and managing risks to patient safety. In Hong
Kong, the Hospital Authority has implemented a comprehensive risk management program
that includes the reporting of adverse events, the investigation of incidents, and the
development of strategies to prevent future occurrences.
 The audit cycle
Clinical governance is an essential component of the healthcare system that aims to
ensure that high-quality care is provided to patients. It is a framework that enables healthcare
organizations to ensure that they are delivering care that is safe, effective, and patient-
centered. Clinical governance encompasses a wide range of activities, including quality
improvement, risk management, and clinical audit. In Hong Kong, the Hospital Authority (HA)
has implemented a clinical governance framework that focuses on continuous quality
improvement.
One clinical governance strategy that has been shown to be effective in improving the
quality of care is clinical audit. Clinical audit is a process that involves reviewing patient care
against established standards and making improvements based on the findings. It is an
essential tool for identifying areas of improvement and ensuring that healthcare providers are
delivering high-quality care (Ghavamabad et al., 2021). The audit cycle is a four-stage
process that involves identifying an area for improvement, setting standards, measuring
performance against those standards, and making improvements based on the findings.
In Hong Kong, medication errors are a significant issue that affects patient safety and
quality of care. According to the Hospital Authority's 2021 annual report on sentinel and
serious untoward events, medication errors were responsible for the highest number of
sentinel events in 2020. To address this issue, clinical audit can be used to identify areas for
improvement and monitor the effectiveness of interventions. The use of the audit cycle can
have a significant impact on the quality of practice in Hong Kong. By identifying areas where
the quality of care may be falling short, healthcare providers can take steps to address these
issues and improve patient outcomes. For example, an audit of medication administration
practices might reveal that nurses are not consistently checking patient identification before
administering medication (Watson and Wu, 2022). This could lead to medication errors and
adverse drug reactions. By addressing this issue through education and training, healthcare
providers can reduce the risk of medication errors and improve the quality of care.
The first stage of the audit cycle is identifying the area for improvement. In the case of
medication errors, the audit could focus on a specific medication or group of medications. For
example, the audit could focus on high-alert medications, which are medications that have a
high risk of causing significant harm if used in error. By focusing on high-alert medications,
the audit can identify specific areas for improvement and target interventions to reduce the
risk of medication errors.
 The second stage of the audit cycle is setting standards. In the case of medication
errors, standards could be developed based on established guidelines and best practices.
For example, the National Institute for Health and Care Excellence (NICE) has developed
guidelines for the safe use of medicines in adults (Watson and Wu, 2022). These guidelines
could be used to develop standards for the safe use of high-alert medications in Hong Kong.
The third stage of the audit cycle is measuring performance against those standards.
In the case of medication errors, data could be collected on the number and types of
medication errors that occur and the circumstances surrounding those errors. This data could
be used to identify patterns and trends in medication errors and determine the effectiveness
of interventions.
The fourth stage of the audit cycle is making improvements based on the findings. In
the case of medication errors, interventions could be implemented to reduce the risk of
errors. For example, the use of computerized physician order entry (CPOE) systems and
barcoding technology has been shown to reduce medication errors. By implementing these
interventions and monitoring their effectiveness, healthcare organizations can improve the
quality of care and reduce the risk of medication errors.
In addition to clinical audit, other clinical governance strategies can be used to
improve the quality of care in Hong Kong. For example, risk management is an essential
component of clinical governance that aims to identify and manage risks that could affect
patient safety and quality of care (West and Coia, 2019). By implementing risk management
processes, healthcare organizations can identify potential risks and implement interventions
to reduce the likelihood of adverse events.
Education and training are also essential components of clinical governance. By
providing education and training to healthcare providers, organizations can ensure that they
have the knowledge and skills necessary to provide high-quality care. This includes
education and training on medication safety, including the use of high-alert medications and
the importance of medication reconciliation.
Conclusion
In conclusion, medication errors are a significant concern in Hong Kong's healthcare
system, affecting patient safety and outcomes. The use of clinical governance strategies and
the audit cycle can help to address this issue and improve the quality of care. Clinical
governance frameworks such as the National Safety and Quality Health Service (NSQHS)
Standards and the Clinical Governance Standard can provide a systematic and
comprehensive approach to medication error prevention and management.
 Moreover, the audit cycle is an effective tool that healthcare organizations can use to
monitor and evaluate their medication management processes, identify areas of
improvement, and implement changes to improve patient safety. The audit cycle involves
planning, collecting data, analyzing the data, taking action, and evaluating the results. It can
be used to identify causes of medication errors, such as communication breakdown,
inadequate training, and lack of resources.
However, the success of clinical governance strategies and the audit cycle in
improving the quality of care in Hong Kong is not guaranteed. There are limitations that need
to be considered. For example, the effectiveness of these strategies can be hindered by
limited resources, lack of leadership, and resistance to change. Additionally, there may be
cultural and language barriers that can affect the implementation of these strategies in a
diverse population such as Hong Kong.
In light of these limitations, it is recommended that healthcare organizations in Hong
Kong prioritize medication error prevention and management through the use of clinical
governance strategies and the audit cycle. These organizations should also invest in
adequate resources and staff training to support the implementation of these strategies.
Additionally, it is important to involve all stakeholders in the process, including patients,
healthcare providers, and policymakers.
Further research is needed to explore the effectiveness of clinical governance
strategies and the audit cycle in medication error prevention and management in Hong Kong.
Future studies could investigate the cultural and language barriers that may affect the
implementation of these strategies and explore alternative approaches that may be more
effective in a diverse population. Additionally, there is a need for research on the long-term
effects of these strategies on patient outcomes and healthcare quality in Hong Kong.
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