1. Selection of opportunities for improvement (Outline for problem)
In 2017, 175 cases of medication errors that caused harm to patient was reported to Pharmaceutical Services Division. 22% of the reported cases involved intravenous (IV) drug administration. In the same year, one case of intravenous drug administration errors was reported in Hospital Kajang which cause very serious harm to patient that required Intensive Care Unit admission and prolong hospitalization.

2. Key Measures for improvement
Indicator was the percentage of correct IV drug administered. The standard set was 100% based on Malaysian Patient Safety Goal No. 7.

3. Process of gathering information
Verification study was done in March 2018 followed by Cycle 1 from April 2018 until June 2018 and Cycle 2 from November 2018 until February 2019. Result from Cycle 1 was evaluated in July 2018 whereas Cycle 2 was evaluated in March 2019. An audit on IV drug administration was conducted in medical wards using structured observational audit form involving 180 samples through convenient sampling. We also explored 65 trained nurses on their knowledge and factors causing incorrect IV administration by using 10 -items content and validated self-administered questionnaire.

4. Analysis and Interpretation
During verification study, only 53% from 180 IV drug administration were administered correctly. From the incorrect administration, 92% was incomplete labeling, 74% was incorrect preparation and 24% was incorrect rate. Pareto analysis showed more than 80% of the factors causing incorrect IV administration were following common practice (32%), unaware of the dilution protocol availability (23%), incomplete labeling (23%) and no counterchecking during administration process (19%).

5. Strategy for Change
Remedial strategies include creating a compact dilution protocol called Medfuse. Medfuse contain 62 common IV medication prescribed in medical ward together with dilution and administration instructions adapted from Jabatan Kesihatan Negeri Selangor (JKNS) Dilution Protocol 2017. It comes with a keychain for nurses to attach to themselves for easy reference. In addition to that, we also distributed a printed copy of Jabatan Kesihatan Negeri Selangor (JKNS) Dilution Protocol 2017 to ward staffs along with awareness training activities, modifying medication chart for counterchecking column and creating pre-printed infusion label.

6. Effects of change
Correct IV drugs administration increased from 53% to 91% in Cycle 1 and successfully achieved the standard of 100% in Cycle 2. Achievable benefit not achieved (ABNA) has reduced from 47% to 0%. Since the implementation, no medication error involving IV drug administration had been reported in Hospital Kajang.

7. The next step
To implement these remedial actions to all wards and further expand the remedial actions to other facilities.