1. Selection of Opportunities for Improvement

Low incidence of appropriate injectable antibiotics dilution and administration (IADAA) in Hospital Tanjong Karang (HTK) had been observed. This study aimed to improve IADAA appropriateness among healthcare practitioners in multidisciplinary wards HTK to optimize antibiotics efficacy and to prevent thrombophlebitis, adverse drug reactions, antimicrobial resistance, morbidity and mortality.

2. Key Measures for Improvement

Indicator was the percentage of appropriate IADAA out of total IADAA. Standard was 100% (Malaysian Patient Safety Goals 2013).

3. Process of Gathering Information

A cross-sectional study was conducted in multidisciplinary wards HTK from August 2018 to February 2019. 148 samples were randomly selected. Phase 1 (August-September) was conducted to verify appropriate IADAA rates and multiple factors. Phase 2 (October-December) involved strategy implementation. Phase 3 (January-February) re-evaluated their effectiveness. Direct observation and data collection form were used to collect demographic profile and IADAA process.

4. Analysis and Interpretation

Rate of appropriate IADAA was 14.2% (n=21/148), ABNA 85.8%. The least IADAA appropriateness was administration duration (18.9%), followed by reconstitution concentration (33.8%) and reconstitution diluents (74.4%). Dilution concentration, diluents and administration routes were all appropriate (100%). Every rare antibiotic initiated by visiting specialists demonstrated 0% IADAA appropriateness. All slow intravenous bolus (SIV) antibiotics were inappropriately administered. According to Pareto analysis, factors which majorly contributed (80%) to the low incidence of appropriate IADAA were unaware rare procedures, unavailability of local protocol, inadequate references and reminders, insufficient knowledge or experience and lack of monitoring.

5. Strategy for Change

“SWeFT” approach involving Administration Sticker with QR code, IADAA Summary Wheel, education material like dilution protocol HTK, HTK/531 Form and IADAA Summary Table was developed. Improving ward pharmacists’ roles in pharmacist rounds, IADAA monitoring and antimicrobial stewardship collaboration were implemented.

6. Effects of Change

Rate of appropriate IADAA was successfully improved from 14.2% to 49.3%, with ABNA reduced from 85.8% to 50.7%. Appropriateness of reconstitution concentration (33.8% to 93.8%) and administration duration (18.9% to 52.7%) improved the most. The rates for uncommon antibiotics demonstrated substantial improvements up to 100%. More SIV antibiotics were being administered within longer durations.

7. The Next Step

Further strategies include design of innovative syringe, regular updates of reference, and periodic audits. Current strategies will also be continued and expanded to other medications and disciplines.