Selection of Opportunities for Improvement

Venipuncture and intravenous (IV) cannula insertions are the two most common sources of pain in hospitalized children. Not managing pain well in children causes a memory of painful events and needle phobia. These then cause avoidance of health care. Even though Pain Free Hospital Programme launched by MOH in 2015, it did not mention on pharmacological pain management in pediatric patients.

Key Measures for Improvement

The indicator used was total of venipuncture done with pharmacological pain management. The standard was set at 80% and agreed in Pediatric Quality Assurance Task Force Meeting.

Process of gathering information

A cross sectional study including all patients undergoing venipuncture at pediatric wards during office hours was conducted to identify the usage of pharmacological treatment. Data was collected using data collection form by observational technique. A self-administer questionnaire survey was conducted on a convenience sampling of 50 respondents (doctors and nurses) from 5 pediatric wards (2AM, 2BM, PICU, NICU, and SCN) to identify contributing factors. Verification study was conducted on October 2017 (N=455), Cycle 1 on February to May 2018 (N=520), Cycle 2 on August to November 2018 (N=613), and Cycle 3 on December 2018 to March 2019 (N=620)


Analysis and interpretation

Verification study showed only 11% use pharmacological treatment during venipuncture and Achievable Benefit Not Achieve (ABNA) was 69%. Contributing factors identified from pareto analysis include unavailability of standard protocol (96%), forgetfulness (64%), unwillingness to wait due to high workload (52%) and unavailability of ready to use sucrose preparation (42%).

Strategy for Change

A standard protocol of venipuncture procedure and reminder stickers were developed. They were distributed with a memo to Pediatric Department. Oral Sucrose and Lignocaine/Prilocaine cream were made available as impress stock. In the second cycle, revised standardized protocol and extended to pediatric clinic. In the third cycle, a pocket size reference was developed and distributed. A series of CMEs & CNEs were held to increase awareness among staffs in every cycle.

Effects of change

The ABNA reduces from 69% to 30%, then 23% and further reduces to 13%. The percentage of venipuncture done using pharmacological pain management improves from 11% to 50%, then 57% and further 67%.

The next step

The protocol will be published in pharmacy newsletter, circulated to all departments to reinforce the protocol utilization and included in house officers’ orientation briefing. Future plan is to extend this project to Pediatric Ambulatory Care Centre and Emergency Department. Ultimately to expand this practice to other facilities in Negeri Sembilan.