hospital medication errors
TRANSCRIPT
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Hospital Medication Errors:
The nurse’s perspective
Carolyn Swift
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AIM for the next 10 minutes
• Commonly seen errors
• Improvements
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• Worked with 10 teams to determine what goes wrong, why and what to do next
• Issues grouped into themes
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Leadership
Education
Daily ward activity
Interruptions
Checking medicines
Omitted medicines
Infusion pumps
Patients own drugs
General issue
Increasing incident reporting
THEMES
Underpinned by
Communication
Prescribing
Discharge meds
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Impact of PRESCRIBING errors
• Consequences for patients and relatives
• Expected to be the ‘gate-keeper’
• Investigation
• Time…
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TIME – on admission /inpatient
• First drug round - inevitable delays
• Info from patient / relatives / carer
• Corrections
• Omitting obvious VTE prophylaxis or symptom control e.g. analgesia
• Can’t read it / parts of it
• Communication breakdown
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DISCHARGE
• Error potential
• Nurses check off all medications
• IDL meds are often wrong
• Time spent seeking medical staff to correct
• Corrected again after pharmacist input
• …
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• MDT input
• Buy-in and decision-making is evident
• Changes tested on a small scale initially
• Data / audit to track what works
• Reliably implemented
• Communication to the MDT
• Sharing
IMPROVEMENTS
are more successful when…
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On admission
• Check with patients / relatives
• Print the ECS and write decisions on that
• Senior review of kardex
Inpatient
• Regular kardex review
• Write decisions to stop/start meds on kardex
• MDT attending Safety Briefings
• Inform nursing staff of all ‘once only’ meds
• Inform nursing staff of urgency e.g. sepsis
Communication and accuracy
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Structured Ward Rounds
• Standard format
• Readily pass on information
• Clarify decisions
• Informs the IDL
• Senior reviews
• Every patient is reviewed reliably every time
Communication and accuracy
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Thank you