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The Scottish Patient Safety Paediatric Programme
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The Scottish Patient Safety Paediatric Programme NHS Borders
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The Scottish Patient Safety Paediatric Programme. NHS Borders. Where are you with respect to the paediatric programme medicines management process. We have begun by reviewing our Medicines Management processes in order to reduce errors in the administration of medicines 1 st Steps - PowerPoint PPT Presentation
Transcript of The Scottish Patient Safety Paediatric Programme
The Scottish Patient Safety Paediatric Programme
NHS Borders
Where are you with respect to the paediatric programme medicines management process
• We have begun by reviewing our Medicines Management processes in order to reduce errors in the administration of medicines
1st Steps
Introduction of the safety measure for administration of medicines by:• Introducing a flowchart for the administration of drugs based on NMC standards for
medicines management• Senior staff observe drug administration using a checklist based on NMC standards
for medicines management• Raising awareness amongst all staff of the need for quiet during drug checking• Use of highlights to ensure all staff know when nurses are checking medicines
eg red aprons; barrier belt• Data display
Existing local data
• Drug error rates Sept 09-Sept 10• Total number of errors: 39
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Sep-09
Oct-09
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Near MissActual
Existing local data
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Drug error times Ward 15 Sept 09- Sept 10
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Existing local data
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Actual Near Miss
PrescribingOmissionWrong Dose/RateWrong AntibioticWrong Drug GivenWrong RouteDrug not PrescribedAnalgesia not givenDischarge Bottle MislabelledDrug ExpiredExtra Dose GivenDocumentation ErrorWrong Discharge InformationCannula Flushed without training
Aim: To ensure that the flow chart is used correctly, during drug administration, 95% of the time
by use of the PDSA ramping up tests 1-3-5 system, in Ward 15, by the end of October 2010
Describe your first (or next) test of change: Person responsible
When to be done
Where to be done
One observation of drug administration will be made of two nurses in Ward 15 using a check list
Lesley Horsburgh
04/10/10 Ward 15
Plan
List the tasks needed to set up this test of changePerson responsible
When to be done
Where to be done
● Staff need to be informed of the concerning rise in drug errors and the plans for change ● Inform all of the staff in the ward that there is a flow chart to be used when administering drugs ● The flow chart will be posted inside the drug trolley and in the IV preparation room ●Observations will be used to ensure the process for drug administration is followed correctly
Lesley Horsburgh
.Week commencing Monday 4th October
Ward 15
Predict what will happen when the test is carried out
Measures to determine if prediction succeeds
●The flow chart will be available●Nursing staff will be aware of the flow chartNursing staff will follow all steps in the flow chartThe flow chart will be used each time a prescribed dose isadministeredThe flow chart will not availableThe flow chart will not be usedThe flow chart was not used on every occasion There were additions required to the checklist
●The flow chart will be available ● The flow chart will be used each time a prescribed dose was administered●The checklist was complete● There was space for all information to be documented● The check list was readily available for the observer
Do Describe what actually happened when you ran the testStudy Describe the measured results and how they compared to the predictionsAct Describe what modifications to the plan will be made for the next cycle from what you learned
First Test of Change
Change 1: One observation of drug administration was made of two nurses in Ward 15 using an observation check list
Change 3:
Change 4:
Change 2:
PDSA CONTINUED
What actually happened– Check list was available and used– Check list required some adaptation e.g. time of last dose not included– 7 Interruptions during procedure– Social chatter during procedure– Red aprons not available
ActionsFeedback to drug administrators following observationsWill include run charts for
No’s of interruptionsNo’s of drug errorsNo’s of checks completeCheck list will be adapted to include time of last dose administered
Where we are with measurement and reporting
• Continuing with observations using 1-3-5 test system– Numbers of interruptions are measurable– Number of completed checks measurable– Number of drug errors measurable
• Ideas for change– Patient safety notice board in drug preparation room– Includes data related to drug errors over past 13 months– Feedback to drug administrators following observations– Will include run charts for numbers of interruptions / numbers of
drug errors / numbers of checks complete
Paediatric Programme Goals - Focused Questions
• Is this work making a difference?– Embraced by ward staff– Talking point for staff therefore raising awareness of problem– Interest in data and becoming involved– Should we be displaying days since last drug error?– Needs balance between ensuring incident reporting and
managing risks
• Currently > ….. days since last drug error
