Game of Zeroes: Zero harm, zero tolerance, zero errors

How an international hospital in Vietnam has zero medication errors related to drug dispensing and administration

Mothers and children are the primary patients at Hanh Phuc International Hospital in Vietnam. Highly sensitive to medication, this patient group equally poses a high risk for medication errors. But the hospital has thus far mitigated this risk, even during the ongoing pandemic.

Hospital Insights Asia speaks with Ms Le Ngoc Tho, Clinical Pharmacist and Pharmacy Quality Manager at Hanh Phuc International Hospital, to uncover best recommendations on a zero harm practice and a zero tolerance system for zero medication errors.

A systemic problem

Ms Le Ngoc Tho, Clinical Pharmacist & Pharmacy Quality Manager

“Medication errors are systemic problems,” this is what Ms Tho wants hospitals to acknowledge in tackling medication errors. Rather than changing behaviours of care providers, hospitals instead need to focus on system errors, although behavioural intervention, such as training and awareness programs, are important in some cases, too.

From January to August 2020, reported medication errors at Hanh Phuc International Hospital are mainly “near misses” in prescription errors and a few adverse drug reactions (ADRs). Prescription errors are commonly caused by inappropriate diagnosis and incorrect medication frequency, route, dose, and instructions.

The system, including physicians, drugs, work environment, and even technology, are related to prescription errors, highlights Ms Tho. Doctors may lack therapeutic training, adequate drug knowledge and experience, and perception of risk. Cases may be too complex. The work environment may lack resources and standardised protocols. Medications can also be confusing, especially those that look alike and sound alike. Further, technologies, like computerised drug information systems in electronic medical records (EMR), may lack clinical decision support programs.

All checkpoints covered

No errors from dispensing and administration mistakes have been reported at Hanh Phuc since January. This is because the hospital was able to identify errors during “near misses” stage, therefore, preventing incorrect drugs from being given to patients, says Ms Tho.

A system like this can be implemented through tracking the entire process from beginning to end, and using root-cause analysis as a crucial part of a zero tolerance system. For Ms Tho, this system is a “multitier intervention process to review medication safety on each step and identify risks proactively.”

Interventions and safeguards at every checkpoint, Ms Tho believes, help identify errors early on. At Hanh Phuc Hospital, such interventions include a review of prescriptions to identify near misses, high alert medication (HAM) colour-coding, double-check of drugs by an independent nurse prior to being administered to patients, and tall-man letters for look-alike-sound-alike (LASA) drugs. Ms Tho’s team annually reviews the hospital pharmacopoeia and the list of HAM and LASA drugs. Gap improvement training and monthly audits are likewise conducted to disseminate awareness for nurses and doctors.

Hospitals can also adopt this same system through interventions for every stage of the process. In the prescribing stage, for example, interventions can include educating healthcare practitioners on safe prescribing and ordering, establishing standard treatment protocols and tracking compliance, performing medication reconciliation before creating medication error and dispensing, reviewing all medication orders and intervening in case of any inappropriateness, and periodically tracking prescription errors and giving feedback to clinicians.

During the storing, preparing, and dispensing stage, Ms Tho suggests interventions such as standardising arrangement and labelling of medications, setting up warnings for high-risk drugs, as well as performing double-checks in all dispensing cases and independent double checks in all steps when using high-risk drugs.

Interventions in the administering and monitoring stage may include applying the eight rights in medication administration (right patient, right medication, right dose, right route, right time, right response, right reason, and right documentation), educating nursing staff on aseptic techniques when preparing medications, tracking nurses’ performance, setting up an online medication error reporting system, and tracking all ADRs occurring through EMRs.

Covering all checkpoints and making sure no mistakes are left unidentified encourage a zero harm practice and a zero tolerance system. Aside from interventions, hospitals would benefit from technological solutions like barcode medication administration system and stronger clinical decision support tools.

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Blame Game: How hospitals can protect nurses

Nurses often take the blame for medication errors. But should they really? How can hospitals support nurses in this blame game?

Imagine this hypothetical but possible scenario: an elderly patient had died from multi-organ failure and blood poisoning. She was accidentally given 10 times her prescribed dose of anaesthetic by a nurse. While the overdose was not the cause of death, the blame fell squarely on the nurse.

Shirley Heng, Chief Nurse, Khoo Teck Puat Hospital

When it comes to medication error incidents, nurses often can become convenient scapegoats or fall-guys. Shirley Heng, Chief Nurse at Khoo Teck Puat Hospital, talks to Hospital Insights Asia on how hospitals can put in place processes and adopt technology to minimise human errors, and foster a “no-blame” culture with a communicative team-based approach.

Finger-pointing doesn’t help

Human errors can happen at any step of the treatment process. Administering medication to patients is often the last mile. Prior to it are other steps such as packing, prescribing, and verifying. Nurses are often blamed because they are the ones tasked to administer drugs to patients and therefore are expected to have ensured the final check.

Yet, penalising human errors, when they accidentally happen, will not prevent future errors from happening. More than helping, the threat of punishment makes nurses more fearful of reporting errors. It does nothing to prevent these mistakes from happening again.

While it’s true that nurses need to understand their responsibility to provide accurate and appropriate care for patients, trusting in their abilities and letting them know they have support from the management are better than blaming them when errors happen.

Errors may be prevented

“To err is human,” as they say. Mistakes happen due to several reasons that sometimes are out of our control. Often, factors related to workload and prescriptions cause medication errors.

Staff shortage leads to a whole bunch of problems. Distractions occur especially when doctors and nurses take on a heavy workload or have many concurrent activities or tasks. But this can be mitigated. For Heng, a dedicated time for medication administration rounds, staff support (for example, responding for each other when patients or another personnel call), and reviewing traditional ward activities may be done to minimise clashing of other activities with medication administration, like ward rounds and scheduling of procedures for patients.

On another note, technological support can address misinterpretations in prescription and medication charts. “We have already shifted to electronic medication order and administration so errors from misinterpretation are minimised, if not removed,” Heng shares.

While no technology can lighten nurses’ emotion or perception of being blamed, Heng believes that technology must be used to “support the care providers involved in every step of medication management, starting from ordering to administration.”

A no-blame culture is key

In case medication errors occur in a hospital, a non-punitive approach must be used. Eliminating a culture of blame makes nurses more open and communicative, which are highly important in mitigating errors early on.

Creating a no-blame culture involves encouraging a root-cause analysis in looking at reported incidents. Reviewing every segment of the process in which errors can happen lets the staff know they are supported. “It is an ongoing battle to investigate error sensitively and ensure our staff, especially our nurses, feel supported as second victims,” says Heng.

An ideal scenario to address incidents should be transparent. The nurse manager receives the first report of the incident, interviews the staff involved, creates an incident report which includes a root cause analysis, and shares findings to various teams for learning and quality improvement.

Equally crucial is using a multi-disciplinary approach. Insights from doctors, nurses, and pharmacists help move the investigation forward. Regular communication, likewise, has to be encouraged for different staff levels.

Blaming will get us nowhere. Besides preventing medication errors, hospital leaders have the responsibility to let their staff know that finger-pointing is the last thing they’ll ever have to worry about as they care for patients.


Catch Shirley Heng on 8 December 2020 for a panel discussion on “Stretching an already stretched workforce: Managing nurses”. Register for HMA Virtual today!

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Medication errors from shortfalls in staffing and technology

The impact of inappropriate staffing and lack of technology on patient care from the perspective of the National Institute of Cardiovascular Diseases

One nurse attending to four patients is what’s ideal in healthcare. Fewer than four is even better. But these are usually not the case in hospitals today, especially in a pandemic situation. The impact of this problem is larger than just human resource management.

Improper patient to nurse ratio prevents hospitals from providing optimal clinical and patient outcomes. At the National Institute of Cardiovascular Diseases (NICVD), this insufficiency in staffing is the main factor associated with medication errors.

Azra Masqood, COO, NICVD

The first tertiary cardiac care institute in South Asia and the flagship facility for cardiology in Pakistan, NICVD sees more than 2 million patients annually. An overwhelming number of patients would ideally require a sufficient number of nursing staff. With a patient to nurse ratio of 6:1, chances of medication errors happening under their watch become higher, says Azra Maqsood, Chief Operating Officer at NICVD.

Yet, NICVD’s plight is not an isolated case. Reports have shown how a lack of nurses can lead to inefficient patient care. Because nurses have to attend to a lot of patients, they are oftentimes in a hurry or distracted. Hence, a number of nurses have missed patient vital signs, made mistakes in delivering medications, and failed to provide psychological and social support to their patients.

COVID-19 magnified the issue even more. Each nurse in one hospital is assigned an exhausting workload from attending to seriously ill patients while staying vigilant with infection control measures. Confusions and overcrowding, therefore, mess with the staff’s fulfilment of duties.

Looking at the ideal scenario where appropriate nurse staffing is in place in a hospital, patient care is better. According to several studies, a proper nurse to patient ratio enhances patient satisfaction and reduces medication errors. When nurses aren’t fatigued, they stay on top of their game and are able to concentrate on their responsibilities as care providers.

Nonetheless, staffing is just one of several factors related to medication errors at NICVD. Masqood recognises how the lack of technological support can be resolved to prevent prescription, dispensing, and administration mistakes.

“NICVD is still young on technology,” she highlights, thus, the hospital still uses handwritten prescriptions, which are sometimes illegible and therefore subject to misinterpretation. Other hospitals are fortunate enough to have an electronic medical records system running, so prescriptions are transmitted in electronic format, thereby, reducing the chance of misinterpretations and mistakes. Realising this hurdle, NICVD has implemented a system wherein prescriptions are read out by the postgraduates, fellows, or residents in each shift.

NICVD is looking at developing its very own digital footprint toward this same cause. Providing medication to the wards on a daily rather than a weekly basis will be one lane in this path, and the other will be implementing “simple barcode reading provided on an in-patient bracelet to be able to provide the right medicine along with the right dosage,” shares Masqood.

While plans are still polished, the present demands a response whenever medication errors happen. AT NICVD, the response primarily concentrates on reviewing and counselling. First, the management needs to identify if it is an “innocent human error.” Is it because of an illegible prescription chart that nurses find difficult to comprehend? If so, the management does counselling for the involved personnel. The same goes if it is a case in the outpatient department and the medication error happened at the side of the pharmacy.

Blaming has no space at NICVD’s response, knowing how punishments and retributions would not solve the problem. At the same time, the problem has several layers under it, like improper staffing and inadequate technological support.

Rather, steps to prevent medication errors are put in place. These include providing standard operating procedures (SOPs) on drug administration to the patient care team, which consists of consultants, physicians, and nurses. Involved with the process are the pharmacy and therapeutic committee that conducts a review on the SOPs. Drug guides are also made available for each shift and a hotline is available for drug guidance in general wards.

Medication errors are preventable, but it won’t be easy if nurse to patient volume is inappropriate and if opportunities to digitise aren’t optimised towards this end.

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Going digital in the era of constant change

Quick access to reliable and accurate information, Dr Han Boon Oh observes, is key to more efficient care and fewer medication errors.

What we know ten years ago is obsolete knowledge. Change is inevitable, and thus, uncomfortable. But the healthcare industry need not flinch, especially at a time when patients have increasingly complex medical needs.

Dr Han Boon Oh, Deputy Chief Medical Informatics Officer and Associate Consultant of General Surgery (Breast and Endocrine Surgery) at Ng Teng Fong General Hospital, National University Health System in Singapore, navigates through these complexities with fast access to medical information. In an interview with Hospital Insights Asia, he shares how updated information is critical in providing care and preventing medication errors.

Better care and higher physician confidence

“Information is crucial in providing care,” Dr Oh emphasises, “since I was a student, I have been enjoying the convenience of UpToDate® and now I am using the app on my smartphone to have quick access to medical information I need.”

For doctors to come up with the best clinical decisions at the point of care, the information they must have at their fingertips have to be accurate and credible. Links to referenced publications, peer-reviewed journals, and recently published discoveries help care providers evaluate the available information, thereby allowing them to make quick but precise decisions for patients.

Relying on evidence-based medicine practices

Medical breakthroughs, new drugs, new clinical trials, and newly debunked healthcare myths are important information that has to be readily available. A doctor cannot rely on “what he knows” just because “it has worked before and for other patients” because, like drugs, information changes over time, too. Otherwise, patients are at risk of serious harm, additional cost, and longer treatment. In the long run, hospitals and physicians carry the burden of an inefficient and inferior quality of care.

But with easy access to up-to-date information, physicians at Ng Teng Fong General Hospital, Dr Oh believes, will be more confident about their clinical practice knowing they are able to give the best treatment for patients.

Dr Oh, for instance, gets to know what’s new in surgery as well as the latest recommendations for surgical topics like groin hernia repairs. UpToDate®, he shares, provides the most recent landmark publications divided into various subspecialties, The “Practice Changing Updates” section in UpToDate highlights selected specific new recommendations that may have a significant and broad impact on practice,  and “this is one of the main things [he] like[s] about using this resource.”

Likewise, in the time of COVID-19, doctors know what to do because they have the updated research and guidelines for appropriate care.

Reducing medication errors

Errors are not an option in healthcare. Hospitals cannot afford to lose patients because these mistakes are generally preventable. Hospitals likewise do not want to lose revenue; these errors already cost the industry more than $42 billion.

There is an overwhelming number of available medications, and this is both good and bad news for physicians, especially when treating an ageing population. This group of patients has increasingly complex medical needs, therefore, multiple medications that need to work concomitantly and safely are prescribed.

Again, solutions proven to have worked several years ago may no longer work today. Physicians, therefore, benefit from having accurate drug information at their fingertips to prevent medication errors and help patients avoid long hospital stays, serious harm, and unnecessary cost.

This is where Ng Teng Fong Hospital sees the advantage of using Lexicomp®, which provides evidence-based referential drug information. With a few quick taps, pharmacists, nurses, and physicians can search for drug information for common medications. The tool also proves useful in making the best and safest drug decisions for each patient.

While there are other factors associated with medication errors, it cannot be taken for granted how quick access to credible and evidence-based information can elevate the standards of care expected from care providers.


About UpToDate® and Lexicomp®

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How Nagoya University Hospital uses up-to-date information to their advantage

Updated information takes the quality of care at Nagoya University Hospital to a whole new level. It improves patient outcomes, clinicians’ skills, and overall quality of care.

We’re living in the information age; every question has a lot of answers and every answer is accessible with but a click. But information, oftentimes, is overwhelming that we aren’t able to optimise its use. Nagoya University Hospital rejects this pessimism as it turns to credible information to fulfil its role as a world-class hospital that promotes a high quality of care.

Japan’s first National University Hospital to receive accreditation from the Joint Commission International (JCI) as a world-class institution, Nagoya University Hospital shares how they use up to date rather than outdated information to enhance decisions, improve clinicians’ skills, and deliver efficient patient care.

Realigning care with the newest evidence

Evidence guides decision-making. We see this not only in hospitals and clinics but also in police investigations and court proceedings. Doctors cannot just decide on a treatment policy “just because other clinicians use it” or “just because they have previously used it for another patient.”

To avoid unnecessary harm and risks to patients, clinicians need to use evidence-based practice, but this is not just about using any evidence available. Rather, it asks for the use of most updated and current evidence. As we all know, the only thing constant in the world is change. What we know to be an effective vaccine or medication a few years ago may not work today.

Without adequate access to up-to-date information, physicians are in trouble for variability in care which can negatively impact patient outcomes. Contrast it with when all clinicians have access to the same medical knowledge, therefore, can collaborate underneath a shared reliance on updated evidence.

No need to know everything

The clinical mind can only take so much information. It also forgets, makes mistakes, and says ‘enough.’ Dr Takeshi Kondo from Nagoya University Hospital’s Department of General Medicine, also a training instructor at two other hospitals in Aichi prefecture, highlights how access to the latest treatment options, clinical successes, and medical findings are key to “deepening doctors’ and trainers’ knowledge.”

In the educational conferences he holds, Dr Kondo sees the wide use of UpToDate®, a clinical tool by Wolters Kluwer, which allows participants to investigate relevant cases, symptoms, treatment methods, and images in order to come up with the best diagnosis.

The same evidence-based resource has been in use at Nagoya University Hospital since 2009 and Dr Kondo has been relying on it for more than 10 years prior to joining the hospital. Through the years, he has observed how UpToDate® helps elevate Nagoya University Hospital’s status as a hospital that plays the lead role to “diagnose cases that are difficult to determine in other hospitals, to examine all possible treatment methods, and to determine the right direction.”

While clinicians always need to continue sharpening what they know, they don’t need to stretch their brains past what they can hold. Evidence-based clinical resources are able to provide them with the most current and relevant information they need to guide their medical decisions.

Patients deserve what’s best

We cannot underscore this enough, but patients require the best care hospitals are able to provide whether they’re inpatient or in visiting medical care. Today, time is no longer an excuse not to thoroughly investigate a patient’s medical history and symptoms to come up with the correct diagnosis.

In the field of visiting care, for example, quick research for more information about a disease is already possible with technologies like smartphones and tablets. Electronic health record systems, too, have proven vital to easily review what drugs a patient has taken, his allergies, his past diagnoses. Patient records are indispensable to making future decisions, Dr Kondo believes.

The accessibility of all such information allows healthcare providers to avoid medication errors. Patients then are given the treatment they deserve based on their preferences and their symptoms.

Making an excuse for slovenly medical care can no longer be justified at a time when information is at our fingertips. Patients expect better outcomes and physicians are expected to use the latest and the most accurate information there is. Updated evidence can just be the key to achieving both.

About UpToDate

More than 1.9 million clinicians in 190+ countries rely on UpToDate® to make the best care decisions and stay abreast of contemporary standards in the workflow and on-the-go. UpToDate is the only resource associated with improved patient outcomes and hospital performance, and studies show that clinicians who use UpToDate change their decisions 30 percent of the time.

More than 7,100 world-renowned physician authors, editors, and reviewers use a rigorous editorial process to synthesize the most recent medical information into trusted, evidence-based recommendations. Every day, clinicians view topics covering 25 specialties over 1.6 million times. For more information, visit

On Asian healthcare’s digital transformation and better quality of care

Norman Deery, Vice President of Clinical Effectiveness, Wolters Kluwer Health APAC, affirms that Asia is all-geared up for a digital revolution in healthcare, and identifies the challenges and opportunities for its realisation.

The future of healthcare is digital, and Asia is poised to take a huge leap to realise its healthcare system’s digital transformation. Norman Deery, Vice President of Clinical Effectiveness at Wolters Kluwer Health for Asia Pacific, believes the region is primed for this as evidenced by the wide adoption of advanced clinical decision support systems during the pandemic. More than 500 thousand UpToDate® users, and a significant number from Asia Pacific countries, have accessed its COVID-19 content topics. 

Deery worked for 30 years in the information technology industry prior to joining Wolters Kluwer, thus, has an excellent understanding of the blueprint underlying digital transformation. Shifting to the healthcare industry because of that “wonderful sense of achievement from helping people and improving the quality of life for others”, Deery shares his vision for a patient-centric health system for Asia – one that could also be prompted by technological innovation.

Digitising healthcare in Asia not only allows for efficient medical processes but also patient safety and clinical effectiveness, which are positively and consistently linked to a higher quality of care. Providing better quality of care, though most vital, is never an easy trail. In Asia, a number of apparent challenges may be addressed through innovative solutions.

Deery observes that physician ratio in the region’s emerging markets is a major problem. To illustrate, the number of physicians per 1,000 people in China is 1.9, in India 0.7, in Malaysia, Vietnam, and the Philippines 1.2, in Thailand 0.4, and in Indonesia 0.2. These numbers are way lower than what communities need considering the increase in the ageing population and the prevalence of chronic conditions and diseases.  All these challenges add to the pressure of providing quality care in the most efficient way possible.  Wolters Kluwer’s solutions help by providing trusted recommendations at the point of care, where it matters most.  A clinician can typically search, locate, and review the information they need in approximately 1 minute.

Healthcare organisations in Asia also struggle to harmonise care across the entire healthcare system. “Medicine has become so fragmented that if you have doctors, nurses, pharmacists, patients, and everyone else in the healthcare continuum all making decisions based on disparate information, you simply can’t provide high quality or very effective care,” Deery says. With an evidence-based clinical decision support tool, however, these providers could have access to up-to-date medical information to help in their decision-making. Hence, they would be able to reduce unwanted variability in care across the system through enhancing medical decision-making and patient assessments, and through proactively alerting prospective patients of issues that need medical intervention.

Another problem, not just in Asia but globally, is erroneous diagnosis and medication. The World Health Organisation reports at least 5 patients dying every minute because of unsafe care, and four out of 10 patients harmed during primary and ambulatory health care due to errors in diagnosis, prescription, and medication. With new technologies like Wolters Kluwer’s UpToDate, healthcare providers can make the best clinical decisions, supported by updated and critically reviewed evidence, to save more lives.

Even in today’s situation where patients and physicians resort to virtual consultations, evidence-based solutions can add value to hospitals. As of date, Wolters Kluwer is working with telemedicine providers in Asia to integrate the benefits of harmonised and evidence-based care to patients. Additionally, Deery mentions that they are currently incorporating their solutions, such as UpToDate, Lexicomp, and Medi-Span, with a variety of Electronic Medical Records (EMR) systems providers so as to contribute to better data management coupled with the improvement of the quality of care.

There is also increasing support from governments and healthcare providers across the region to swiftly employ digital technologies. Over the years, governments are observed to increase their healthcare spending, thereby, increasing confidence that they would give continuous support to the health sector. Healthcare providers and patients likewise show eagerness in using mobile technologies and cloud-based solutions, hence, putting pressure on hospitals to integrate such solutions into their organisations.

Step by step, Asia could transform its healthcare system towards becoming more digital, not because other regions are doing it, but because of the necessity of providing better care for patients through proven technological solutions.

About UpToDate

Researchers at Harvard associated the use of UpToDate, the only clinical decision support resource associated with improved outcomes, with lower mortality rates and shorter lengths of hospital stay. Several other studies confirm UpToDate’s impact on learning, better clinical decisions, improved quality of care, patient safety, efficiency, and mortality.

The Medical City’s evidence-based practice

Dr Rafael S Claudio, Chief Medical Officer of The Medical City, trusts that evidence-based practice can help hospitals achieve clinical efficacy and thus optimal patient outcomes.

Imagine you have an elderly patient who has been diagnosed with stage 4 colorectal cancer with multiple options for medical and surgical options for management. As a general practitioner, how do you determine the best treatment plan for the patient? This might be an easy question at a time when the internet was just an idea. Now that the internet provides a vast amount of knowledge, you won’t find it easy to pinpoint the most accurate information to help in your decision-making process as a clinician.

A growing healthcare network in the Philippines, The Medical City (TMC) experiences the same dilemma as it strives to provide patients with consistent quality outcomes. Dr Rafael S Claudio, Chief Medical Officer of TMC, tells Hospital Insights Asia that ensuring the quality of care and pursuing clinical effectiveness can be tough when there are inadequate and incorrect data to verify treatment practices.

Dr Claudio believes that clinical effectiveness is the end goal of healthcare as “it determines whether or not illnesses are prevented and cured, and whether or not patients are adequately and satisfactorily cared for”. There is a wide belief that clinical effectiveness can be realised through evidence-based practice as it promotes the Triple Aim of healthcare: improving quality of care, improving patient satisfaction, and reducing the cost of care.

Evidence-based practice in healthcare means making clinical decisions that are supported by scientific research. Not only does this eliminate outmoded medical practices, but it also ensures the use of validated data coupled with clinical expertise and consideration of patients’ needs. Hence, variability in care and medication errors are avoided, thereby also enhancing patient outcomes and upholding quality but affordable care.

Then again, how can hospitals in Asia follow evidence-based practice? Staying up to date with the most current scientific knowledge published on the Web itself means reading 17 articles per day for one year. Doctors do not have the time to read this number of articles on top of their clinical duties.

TMC has turned to UpToDate, a clinical decision support tool by Wolters Kluwer that Dr Claudio describes as a “one-stop-shop for diagnosis and recommendations”, to solve this difficulty. TMC’s consultants use UpToDate for their outpatient clinics as a point-of-care tool, while the hospital’s trainees and students use it as a reference tool for research and team discussions. As a matter of fact, Dr Claudio notes that TMC has observed significant improvement in research work and regular conference reporting with the availability of appropriate resources from UpToDate.

Another challenge lies with disputing the deep-rooted resistance clinicians may have to adopt new practices. The best chance of success lies with getting all your clinicians on board with solutions that do not over-burden them with processes. A clinical decision support system that delivers trusted, relevant content seamlessly to clinicians as part of their workflow is essential.

Without having to pore over 17 articles a day, a paediatrician at TMC shares that she “can refresh [her] knowledge base and be in the loop whenever new treatments are available”. Dr Claudio reveals that TMC chooses to use UpToDate because of its comprehensive and authoritative source of evidence-based medicine reviewed by experts, an extensive collection of clinical topics including drug information, regularly reviewed and updated topics, variety of medical calculators, simple interface, and ease of access. 

While there may be other available clinical decision support tools in the market, UpToDate serves as an instrument that delivers accurate answers on clinician’s queries related to patient care that is parallel to TMC’s vision to provide quality medical care and adopt healthcare innovation, says Dr Claudio.

As Dr Claudio highlights, finding the most accurate and reliable information especially in the medical field will always be challenging, but investing in a knowledge management system or an evidence-based resource holds enormous potential for improving the quality of services being offered in a hospital.#

About Wolters Kluwer

The Clinical Effectiveness solutions from Wolters Kluwer help healthcare organizations and professionals harmonise care and improve patient outcome by aligning decisions. Care teams in over 190 countries make evidence-based decisions with Lexicomp®, Medi-Span®, and UpToDate® in their workflow.

Learn how Clinical Effectiveness solutions can help your hospital achieve harmonised care.

Patient outcomes, the be-all and end-all of healthcare — Asian Hospital

Dr Ana Maria Jimenez, Quality Management Director of Asian Hospital and Medical Centre, shares how the availability of a clinical decision support technology helps reduce variability in care and provide better patient outcomes as a whole.

Quality is measured by the outcomes that matter to patients, and underlying patients’ total experience influencing patient outcomes is clinical effectiveness, Asian Hospital and Medical Centre (AHMC)’s Quality Management Director Dr Ana Maria Jimenez remarks. Critical in ensuring application of best knowledge from up-to-date evidence, clinical effectiveness helps “to achieve optimum processes and outcomes of care for patients”. As one of the Philippines’ most advanced healthcare institutions, AHMC strives to consistently work on its clinical effectiveness strategy.

Yet, Dr Jimenez admits that it is an uphill struggle. AHMC, for instance, faces several challenges in its goal to ensure patient safety. Primarily, the issue lies in insufficient references that are both reliable and accessible to help physicians make informed decisions. Added to this is the variability in care that significantly reduces efficiency.

According to the World Health Organisation (WHO), 4 in 10 patients globally do not receive proper treatment even though the harm they suffered could have been prevented. Should more physicians and hospitals have available clinical resources at their fingertips to help them properly diagnose these patients and provide them appropriate care, more lives could have been saved and more patients could have been satisfied with their healthcare experience.

Dr Jimenez points out that the lack of relevant resources is not only a struggle in providing point of care decisions, but also during morbidity and mortality case reviews, investigation of an adverse event, appropriateness review of drugs, adoption of clinical practice guidelines, pathways, bundles of care and/or protocols, and writing or reviewing policies on patient safety.

On a similar note,  variability in care can create problems that could ruin outcomes improvement for any hospital. In 2016, for example, a hospital in Australia lost a patient due to medication overdose as he was given ten times the prescribed amount of an opioid painkiller. This happened due to the inconsistency of clinical knowledge between the physician and the nursing staff. In AHMC, at least 80% of patient safety events are related to outdated practices and lack of collaborative care among multidisciplinary team members, Dr Jimenez tells Hospital Insights Asia.

In today’s digital age when information can come from everywhere, more patients can suffer from a variation of care. Due to the massive amount of information now available, it can be difficult for physicians to make informed decisions in line with a patient’s needs. 

To reduce variability, hospitals can consider using clinical decision support technologies. Considered as new opportunities to reinvent healthcare by enriching clinical effectiveness, such tools can reduce cost (i.e. lesser wasteful testing and reduced emergency room use) while improving the quality of care given to patients.

Committed to embracing “innovations in healthcare for an unforgettable healing experience”, AHMC consistently looks for ways to be on top of the game towards providing the best care for its patients. Two years ago, AHMC started using UpToDate, an evidence-based clinical resource by Wolters Kluwer. By and large, this move is meant to equip the staff with the most recent and reliable clinical information that can translate to standardised care and eventually better patient outcomes.

Dr Jimenez reveals that AHMC’s ICU Intensivists and Fellows are among the primary users of UpToDate. They discovered that this clinical resource is a helpful tool in their department as they examine drug information, find treatment recommendations, and give information to patients. In fact, AHMC finds a decreasing trend in the ICU standardised mortality ratio over the past two years since they have adopted UpToDate.

More recently, AHMC finds UpToDate really useful in their response to the COVID-19 emergency. The hospital’s Multidisciplinary Healthcare Team refers to UpToDate and its resources on the infection which are updated on a daily basis, says Dr Jimenez.

Thus far, Dr Jimenez sees UpToDate as a solution that supports AHMC’s goal to continuously ensure patient safety and enhance clinical effectiveness. Likewise, she believes that other hospitals can experience the same benefit from using UpToDate in line with evidence-based practices. Its ease of use, accessibility via mobile applications, organised and in-depth reviews, graphical presentations, link to LexiComp drug database, and use of GRADE approach for recommendations are just some of the features that Dr Jimenez believes would directly help hospitals optimise this tool to provide topnotch care for patients.

It is definitely looking way ahead to say that evidence-based practice might lower the number of adverse events from unsafe care that can be preventable with the presence of sufficient and tailored resources to support clinical decisions. Still, a decrease in mortality and an increase in satisfied patients are something the healthcare industry remains optimistic about. 

Improving quality of care may be an expensive venture. Nonetheless, the failure to seek improvement in care can be even more expensive. After all, the WHO recognises how “investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes”.#

About UpToDate

An evidence-based clinical decision support solution used by more than 1.7 million clinicians in 190+ countries to make important day-to-day clinical decisions, UpToDate is the only resource associated with improved patient outcomes and hospital performance, and studies show that clinicians who use UpToDate change their decisions 30 percent of the time. More than 6,900 world-renowned physician authors, editors, and reviewers use a rigorous editorial process to synthesize the most recent medical information into trusted, evidence-based recommendations. Every day, clinicians view topics covering 25 specialties over 1.5 million times.

Boost the confidence of your clinical decisions by understanding the grading strength of recommendations and quality of underlying evidence.  Download the below whitepaper to learn more.

Is ‘zero harm’ possible? A Singapore hospital’s story

The Chief Risk Officer of KK Women’s and Children’s Hospital shares her experiences in promoting a culture of safety.

What are the real-life consequences of unsafe care? In high-income countries such as Singapore, one in every ten patients is harmed while receiving hospital care – but nearly 50 percent of these cases are preventable, according to the WHO.

Hospitals have the opportunity to create a culture of “speaking up for safety” amongst staff, no matter their level of seniority, says Pang Nguk Lan, Chief Risk Officer and Director of the Department of Quality, Safety and Risk Management at KK Women’s and Children’s Hospital (KKH). This could potentially prevent safety incidents and ‘adverse events’, lead to long-term cost savings, and even save lives.

It is not about pointing out mistakes, Pang notes. Rather, it’s about “helping you see something that you cannot see at that point,” Pang says on the sidelines of Hospital Management Asia in Hanoi last year.

Making patient safety a strategic priority

In 2015, KK Women’s and Children’s Hospital made ‘Target Zero Harm’ by 2022 a strategic priority. This is a comprehensive programme made up of workshops, feedback reporting, and continuous learning and process improvement through town hall meetings.

Part of this initiative was to tackle certain cultural aspects in Asia, where junior members of staff may feel hesitant to share their views with senior management, or those with more experience. “We felt that we needed to bring in a programme to get our staff speak up on their concerns for safety without fear,” Pang says.

The hospital had identified early on that people and culture were essential to achieving zero harm. It worked with an external trainer to conduct patient safety workshops, training staff of all levels on how to tactfully and effectively share their feedback with others. It has also built an online reporting system for staff who are still not comfortable voicing their concerns publicly.

What’s more, the hospital has trained “peer messengers” whose responsibility is to relay any safety concerns from the online reporting system to the relevant people, she adds. “We want people to be accountable,” Pang says.

A post-training survey revealed how 82 percent of hospital staff are now comfortable with speaking up about safety concerns, thanks to these initiatives, according to Pang. These efforts have translated into very real cost savings for the hospital, too. It has saved nearly $200,000 by preventing urinary tract infections caused by catheters.

“It doesn’t mean no mistakes, because we are all human,” Pang goes on to say. “Once you have the mindset of Target Zero Harm, in whatever things we do, we will make sure that any job given to me, I will do it well, in a way that I will make good choices.”

Here is how it works in practice. In 2019, senior patient care assistant Sa’ad Siti Aishah had noticed something amiss when she checked on a patient before an operation. Siti spoke up and shared her concerns with a ward nurse and then again persuaded her to check with a doctor when the ECG results did not reveal anything unusual.

A CT scan was then arranged which showed a blood clot in the patient’s brain – deeming her unsuitable for surgery. “We are not looking for credit or pinpointing other’s mistakes; we are encouraging each other to save lives and prevent harm from reaching our patients,” she said.

Addressing risks together

Another aspect of Pang’s work involves risk management, which is essentially a more proactive way of addressing safety risks. Simply reacting to safety lapses when they happen is “not a very smart way of doing it, because you are just fighting fires, and things will still occur again,” she points out.

The key to risk management is to break down the silos between care teams. This means bringing together doctors, nurses, aides, facility management, environment services, and even administrative staff to examine a specific problem from all sides, Pang says. “When we do risk assessments, we bring everybody together to work as a team.”

These assessments reveal that sometimes, what the staff thinks the patient needs may not be what the patient wants. Take patient falls, for instance: nurses may think that the best solution is to help the patient to get to the bathroom, according to Pang, who spent twenty years as an ICU nurse. But patients may in fact want to be more independent, or may not want to trouble the nurse every time nature calls, she notes.

It therefore becomes a matter of designing a safer environment for the patients: putting in more grip bars and anti-slip mats in the bathrooms, Pang explains. Here is where it is helpful to get insights from the people who manage the facilities.

“It’s quite rewarding because when we gather people together,” Pang goes on to say. “They are able to work together as a team and meet up to the patients’ needs, and meet our staff needs, and also make ourselves safer.”

She believes that “people are our asset”. Well-trained and engaged hospital staff are in fact empowered to “do wonderful things”. This also means creating a purpose and meaning for all staff – showing them how they all contribute to better outcomes for their patients. “Whenever we do anything, we should look at how we could add value to our patients, rather than just doing things as a task,” Pang concludes.

It should be a given for any patient to enter a hospital and expect high quality and safe care. As healthcare advances across Asia, patient safety is fast becoming an essential priority of any provider.

Image by KK Women’s and Children’s Hospital

DORSCON Orange Is The New Black

A senior emergency medicine consultant’s experience of dealing with COVID-19 from the frontlines in Singapore.

Singapore, 13 February 2020 – Here we are in Week One of the new national code DORSCON Orange in response to COVID-19. Essentially, the Disease Outbreak Response System Condition reflects the current coronavirus disease 2019 situation. In DORSCON Orange, disease is severe and spreads easily from person and person. The restrictions that come with DORSCON Orange could cause moderate disruption, such as temperature screening and visitor restrictions at hospitals.

In addition to the social advice to stay home if one is sick, maintain good personal hygiene and look out for health advisories which should surely be a daily standard, the only new one is to comply with control measures. OK, that doesn’t sound so bad. On the ground, what’s really happening though? And how did we get to this state?

No holiday cheer
Merry Christmas (25 Dec- 5 Jan)
The Grinch That Stole Christmas Is A Virus

As a healthcare worker in frontline critical care, I have to say, it’s pretty overwhelming. Having worked through Christmas, to throngs of unwell patients, I was almost at the end of my tether. I remember handing a New Year’s Day shift over to a colleague, telling him that there was a zero-bed situation and a long waiting time for minor emergencies. Just then, we received word about an unknown virus originating from Wuhan.

At first, I thought it was a joke, some fake news that would soon be debunked. In fact, my husband & youngest son left for a family holiday in China on the last day of Christmas. I stayed home and monitored the situation from work. Subsequently, news came of mortality & morbidity from patients in China as well as the arrival of the virus in Singapore.

Chinese New Year (25 Jan-8 Feb)
Now In Fashion

By the time Chinese New Year rolled in, we really felt the heat. First of all, with every shift, my colleagues and I were revising new protocols to screen patients, initially just from Wuhan, then from all of mainland China. A plethora of other associations met case definition as well, including contact history and symptoms. We started going for training sessions to put on protective gear which many hadn’t touched since SARS.

Moreover, there were of course our regular patients, including critically ill ones, whom we were now resuscitating with N-95 masks and goggles. I made small jokes about our outfits of the day. These accessories would not pass muster in Next In Fashion! N-95 masks caused zits and the goggles interfered with my eyelashes which are as long as they are fake. In the infectious disease annex, the full gear made us perspire and my hair was hopelessly flat.

On a serious note, it was physically and mentally exhausting, with little respite. Sleep was always interrupted by the sound of my phone purring away with new case definitions and protocols on Tiger Connect, WhatsApp and email. Hence I hardly went for any Chinese New Year celebrations including my own. At our open house celebrations, I only stayed for an hour before dashing back to the hospital.

How very Black Mirror

When I did get a chance to meet friends, I found it striking how quickly news traveled. Often they would know about private memos before I received them from the ministry. As quickly as they absorbed knowledge, they formed and shared opinions via social media.

These opinions were varied. Some were quite flippant, deriding others for their panic, sending ridiculous photos of people with water tanks on their head as protection. Some were quite frightened, discussing various ways to now safely touch a lift button. Who were proven right ultimately? The answer is, we don’t quite know yet. Perhaps the truth is somewhere in between.

By now, we do know that human-to-human transmission started much earlier; we just didn’t know how to interpret the data from the initial cluster. We also know that as the incubation period is at least 24 days and one can be infectious without displaying symptoms. This suggests the virus is in the community already and our ring-fencing efforts, though valiant and incredibly extensive, weren’t enough.


Has the virus outsmarted us? I don’t think we were ever really on a level playing field.

Viruses have been around a long time. Some deadly ones, after wreaking much havoc, like smallpox, have gone away with vaccination. Some horrible ones like Measles, after being initially quelled, have returned due to the strange phenomenon of anti-vaxxers. Influenza is in the community, with some strains reduced with vaccines yet still causing severe infections in the brain and lung. Antibiotics are currently useless against viruses.

This coronavirus is in multiple countries (although, curiously not in Indonesia). So what can we do?

Singapore Unsocial

Physically, we can reduce transmission by being sensible about personal hygiene. Mentally, we can set intentions to be mindful about our behaviour. That includes not being accidentally racist, like persistently calling the virus Wuflu or Wumonia. To be honest, I myself was guilty of this in the first week when I thought I was being a funny wordsmith. However, there is nothing funny about discrimination.

Socially, there is so much we can do. We went into DORSCON Orange on Friday, the 7th of Feb, when I worked overnight. The next day, when I left work, on Chap Goh Mei, the last day of Chinese New Year, the shelves were swept clean. My nurses and young doctors were frightened as they could not find milk or rice for their children. There was nothing left, not even online.

To make mattes worse, my nurses & I couldn’t hire cars to take us to and from the hospital. Food deliveries were cancelled so small treats like bubble tea were out of the question. Elsewhere, paramedics were shunned.

Frankly & Gracefully

These are the events that led up to DORSCON Orange as experienced by myself and my colleagues. In no way does the narrative reflect the opinions of any senior officials from the healthcare system. Nor do we mean to throw shade at anyone in particular. It is the way it is. Welcome to Week 1 of DORSCON Orange, reporting live from the frontline.

This article was reproduced with permission and originally published here