a medication safety huddle “#druggle · “#druggle” @drashleyreece zahida hassandin premji...

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“#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication Safety Huddle Watford General Hospital

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Page 1: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication

“#DRUGgle”

@drashleyreece

Zahida Hassandin Premji

Lead Pharmacist for Paediatrics

Dr Ashley Reece

Consultant Paediatrician

A Medication Safety Huddle

Watford General Hospital

Page 2: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication
Page 3: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication

Driver Diagram

The Goals

Towards zero drug

errors

Primary Drivers

Reduced prescription

errors

Reduced administration

errors

Secondary Drivers

Doctor/Nurse ownership

Projects

DRUG-gle

Induction teaching/test

Ward Round chart review

On-ward chart review

Culture of drug safety

Pharmacists/team integration

Page 4: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication
Page 5: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication
Page 6: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication
Page 7: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication

DRUG-gle

• At end of Grand Round/Handover

• Pharmacist led

• Key interventions from past week

• Summary circulated

Page 8: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication
Page 9: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication
Page 10: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication

• “Let’s do the #DRUGgle”

• #NEOdruggle

• #NURSINGdruggle

Local Spread…

Page 11: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication

#DRUGgle

National Spread…

Page 12: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication

#DRUGgle

Examples of key messages

Transcription error

Regular medications

Levels

Interactions/effects

Metolazone prescribed instead of mesalazine.

Lanzoprazole: Taking 15mg at home; prescribed at 50mg

Gentamicin: Reminder levels on day 2 and 5. Day 5 level had been missed

Ciprofloxacin and epilepsy:

It can reduce seizure threshold

Type of error Details Details

Page 13: A Medication Safety Huddle “#DRUGgle · “#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication

Acknowledgements

“#DRUGgle”

@drashleyreece

SAFE team:

Peter Lachman, Darren Cooper

Leeds Teaching Hospitals

Neonatal Unit

Paediatric Pharmacists:

Zahida Hassandi

Anupam Paul

Maddie Wong

Alistair Hill