Outline of problem: Clozapine is a gold standard for the treatment of resistance schizophrenia. However clozapine have many side effects that warrant the need of blood monitoring as well as side effects monitoring as recommended by FDA. Failure to adhere to clozapine therapy monitoring can cause late detection of side effects which may lead to serious complications. Serious side effects such as agranulocytosis can increase risk of infection; undetected case of constipation can cause paralytic ileus and hyper salivation that may lead to aspiration pneumonia. Proper monitoring of clozapine therapy reduces the risk of mortality rate from agranulocytosis.
Key measures for improvement: Key indicator for improvement was measured using percentage of patients adhere to clozapine therapy monitoring. The standard set is 100%.
Process of gathering information: This was a cross-sectional study, which involves a verification study (September 2017) and 1 post-interventional cycle (October 2017- April 2018). All treatment resistant schizophrenia patients on clozapine in Forensic and Agrotherapy Male Wards were included in this study. Tools use for data collection were Psychiatric case reports, lab investigation results, clozapine side effects and infection checklists, pre and post questionnaire, medication chart, clozapine monitoring excel sheet and data generated from Pharmacy Information System (Phis).
Analysis and Interpretation: During verification, 39 patients were audited and 0% (n=0) of patients adhere to clozapine therapy monitoring. Only 85% (n=33) received blood monitoring and 0% (n=0) adhere to side effects and infection monitoring. Main contributing factors were unavailability of Clozapine Monitoring tools / system (66.6%), lack of knowledge among ward staffs (71% staff scored less than 80% from pre-test conducted) and lack of awareness where 30% of them did not aware of clozapine monitoring standard.
Strategy for Change: The strategy implemented were establishment of blue Clozapine tag, clozapine’s side effects and sign/symptoms of infection checklists, Clozapine corner, blood drawing schedule, creation of centralized clozapine blood monitoring Excel sheet for pharmacist supervision, clozapine booklet and providing CME for staffs.
Effects of change: The adherence to clozapine therapy monitoring increased from 0% to 100% in cycle 1 and targeted standard of 100% had achieved. The ABNA had reduced from 100% to 0%.
The next step: To broaden clozapine therapy monitoring to other wards. To create proper clozapine monitoring system that incorporated into Phis.