Developing Evidence Based Practice using Practice Guidelines

Monash Medical Centre ‐ Clayton

23 March 2009

Moorabbin

Bed Numbers across 5 sites

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Clayton 731 beds (634 + 97 day beds)Dandenong 520 bedsKingston 550 beds (RASP)Moorabin 93 beds + 35 chairsCasey 229 bedsCICC 16 beds + 12 chairsCommunity 54 beds

TOTAL 2052 beds + 47 chairs

Southern HealthVictoria’s largest health serviceServices a population of 866 000 .Employs almost 12,000 people (6000 nurses)Last financial year• We treated more than 178,000  people• We performed nearly 40,000 operations• Treated 150,000 emergency presentations

• We celebrated more than 8,200 births and

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5.3.3 Patient Identification in Administration of Medicine 

The Regional Hospital Viborg, Kjellerup, Skive

PurposePatient group/patient pathway/other target groupDefinition of conceptsProcedureDocumentationResponsibility References

PolicyPurpose Ensure correct administration of medicine to the correct patient.

Patient group/patient pathway/other target groupThe Regional Hospital Viborg, Skive, Kjellerup 

Definition of conceptsAs a main rule, the patient cannot be correctly identified by name alone; the civil registration number (CPR number) must be used.

PolicyProcedure 

A patient is correctly identified when the patient has given his or her name and civil registration number. If the patient cannot make this identification the nurse must ensure that it is the right patient by checking the identification bracelet. Identification must take place prior to any action directed at the patient including dispensing and administration of medicine. The medicine must be handed directly to the patient and the patient must identify him or herself at the same time. If the patient is not present or is asleep when the medicine is handed over it is not allowed to place the medicine on the bedside table. A note is left informing the patient how to get the medicine.

Policy

ResponsibilityThe person administering the medicine is responsible for administration of the correct medicine to the correct patient.

Clinical Guidelines and Evidence Based Practice

What is this about?

and 

What can it achieve ?

Practice – quality of care30 ‐ 40% patients not receiving care according to scientific evidence*

20 – 25% receive care not needed or potentially harmful*

Cancer care outcomes – improved by 30%, 10% reduction in mortality**

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Medication Errors

Medication Errors are defined as the preventable inappropriate use of medication.

Errors can occur at any point in the process:

Hughes RG, Ortiz E. (2005). Medication Errors: Why they happen, and how they can be prevented AJN 105(3) Supp 14-24 .

Medication ErrorsCan occur at any step in the medication management process: 

– Prescribing errors– Transcribing– Dispensing errors– Administration errors including errors of omission and double dosing, timing errors

– Recording errors – Monitoring adverse events(Australian Council for Safety and Quality in Health Care, 2002; Hodgkinson

et al., 2006)

Risk Factors for Medication Errors

Due to inadequate communication between patients and health professionals, and between health professionals themselvesOverwork and fatigue of prescribersInterruptions to dispensing“look alike sound alike” medication names (dispensing and administration of medications)Inadequate continuity of care between inpatient and community careMultiple health care providersPoor consumer understanding of generic and trade names of medications

Types of medication errors in general medical practice

Type of incident Rate per 100 incidentsInappropriate drug 30

Prescribing error 22

Administration error 18

Inappropriate dose 15

Side-effect 13

Allergic reaction 11

Dispensing error 10

Overdose 8

Systems inadequacies 7

Drug omitted or withheld 6Hodgkinson B, Koch S, Nay R, Nichols K. Strategies to reduce medication errors with reference to older adults. International Journal of Evidence-Based Healthcare 2006;4:2-41

Education and training

There is no evidence to suggest that education addressing medication calculation, or a yearly medication examination is effective in reducing medication errors.

Pharmacists There is some evidence to suggest a role for clinical pharmacists in preventing adverse drug events in the inpatient setting.

Nursing care models

There is no evidence to suggest that providing designated nurses to dispense medication significantly reduces the incidence of medication errors.Use of the focused or Medsafe protocols in which nurses are identified as 'not to be disturbed' can reduce distractions to nurses during medication administration.

Partners in patient care

There is limited evidence to suggest that introducing the PIPC model significantly reduces the incidence of medication errors.

Corkscrew Model of error reduction

At the top (or blunt) end of the corkscrew lies leadership––the chief nursing administrator and nurse managers.

The corkscrew is circular and interdisciplinary––health care system transactions don’t involve only nurses and physicians. What are the roles of admissions, pharmacy, laboratory, respiratory, and even maintenance personnel in ensuring patient safety?

At the sharp end, is medication administration. It’s there that pharmacy and nursing personnel must function together.

Communication is bidirectional

Rich, V. (2005). How We Think About Medication Errors: A model and a charge for nurses AJN 105(3) Supp 10-11 .

Simple FormulaFive RightsRight PatientRight DrugRight DoseRight RouteRight Time

Elements of the Integrated Model

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Research

Education&

Professional Development

Integration of Research

into PracticeAnd PracticeImprovement

Leadership

Safe Patient Care

Change mgtClinical Guideline

IN-REPIntegration of Research, Education & Practice

VISIONTo develop a culture across Southern Health in partnership with Deakin University that integrates Research, Education & Practice (IN-REP) for the delivery of safe patient care.

STRATEGIES•Grand Rounds across sites:

reviewing patient safety and raising clinical governance awareness

•An education program that supports evidence based practice improvement•Developing practice improvement and policy based on best available evidence •Action Learning sets with managers & associates•Leadership breakfast

OUTCOMESTo be nationally and internationally recognised as an organisation that delivers evidence based patient care that is developed and supported by its:

research & professional education programspractice improvement activities.

Education &Professional development

LEADERSHIPA culture of

clinical inquiry &

clinical governance

Monitoring & evaluating patient care

Supporting a research program

& agenda

Development of Evidence based

Policies & procedures

Adopter CategoriesInnovators 2.5%

Early Adaptors 13.5%

Early Majority 34%

Late Majority 34 %

Laggards 16%

Transfer strategies

Educational Outreach

Local Opinion Leaders

Audit and Feedback

Reminders

Educational materials

Cochrane Reviews

Change management and evidence based practice

Change Management

a process and a strategy that can lead to utilization of research findings and improved outcomes for consumers, students, and patients (CIHR, 2004).

Change management strategiesInterventions of implementing research findings in practiceEducational materialsConferencesLocal consensus processEducational outreach visitsLocal opinion leadersPatient‐mediated interventionsAudit and feedbackRemindersMarketing

An active approach with multifaceted interventions based on the assessment of barriers and educational outreach is most 

successful

www.southernhealth.org.au

Elements of change

•Pressure for change

•Organisational’s capacity for change

•Detailing a clear vision

Element 1: Pressure for change

• The pressure for change has already come from the external environment (i.e., Need to implement the guideline)

• This pressure must siphon to lower levels management so staff appreciate the need for change

Possible implication of missing this element

Change put at bottom of “things to do” list.

Background – The necessity for change

Patient Safety

Element 2: Clear vision

•Nurses need to be clearly communicated the change that will occur and the reasons for the change

Possible implication of missing this element

Change starts quickly but does not build momentum.

What needs to be changed?Structure

• Clarify how we will perform the tasks• Educate staff

Technology• Do we have the right equipment

People• Inject a culture of safety

Element 3: Capacity forchange

• Clear vision• Education• Discussion time• Complete checklist

Possible implication of missing this element: 

Change causes anxiety and frustration because it is difficult to implement.

Other elements of change

Actionable first steps

Model the way

Reinforce the change

Evaluate and improve the change program

Element 4: Actionable first steps

Determine what behaviours can be changed immediately, implement the change, and provide support so that the change is successful

Possible implication of missing this element:

Haphazard efforts, disillusionment with the likelihood of success.

Possible emotional responses to change

Denial• No change in nurses’ behaviours

Resistance• Anger, depression, fear, frustration, self-doubt,

uncertainty, thoughts of leaving hospital, greater sick leave, more accidents, increased work-related illnessesExploration

• Nurses feel better about the change and any health issues experienced in the previous stage should subsideCommitment

• Desired behaviours are occurring

Addressing the emotional responses

Denial• Communicate clearly the reasons for, and details of, the change,

and encourage nurses to ask questions Resistance

• Allow nurses to express their issues, encourage them to share their issues with other nurses, listen, and organise pleasant occasions to mark the transition Exploration

• Encourage creative solutions to problems, provide clear direction, and clarify roles Commitment

• Ensure structures and systems are in place, which support the new behaviours

Element 5: Model the way

Ward Nurses and other managers need to behave in ways that are consistent with the vision

Possible implication of missing this element:

Cynicism and distrust with management.

Element 6: Reinforce the change

Recognise or reward nurses that are behaving in ways that are consistent with the vision

Consider encouraging nurses who remain resistant to the change to come on board or move on

Possible implication of missing this element:

Nurses will return to old behaviours.

Element 7: Evaluate and improve the change program

Take baseline measurements and reapply those measures after the program has been going for some time (e.g., 1 to 2 years)

Look to measure each change element

Possible implication of missing this element

Scepticism about whether the change has improved the organisation. Stagnation of the intended change

may also occur.

Putting the theory into practice

Key points with which to conclude

• We have reviewed a model of change, but it is only a model

• Important factors that underpin the success of change models are the personalities of the people leading the change

It’s all about people!

It’s all about you!

Think about it!!