smooth safer medica:on outcomes on safer medication...
TRANSCRIPT
SMOOTHSafer Medication Outcomes On Transfer Home
www.koawatea.co.nzH E A L T H S Y S T E M I N N O V A T I O N A N D I M P R O V E M E N T
Background:The SMOOTH programme included:Improving Patient and Whaanau Welfare by• Ensuring accuracy and reliability of information at discharge • Providing tailored patient and whaanau centred education and empower patients to self manage medications• Coordination of timely access to discharge medicines • Establishing a phone call follow up service within 7 days of discharge
Collaborating with other health professionals within Counties Manukau Health to:• Improve the satisfaction of stakeholders through more timely and accurate flow of information regarding medicines and improving acute care demand management through a reduction in readmissions
A safer journey from hospital to home
SMOOTH Safer Medica:on Outcomes On
Transfer Home Aim The aim of the SMOOTH Programme is to reduce medica6on related readmissions by providing 90% of high risk adult medical and surgical pa6ents with a medica6on management service at discharge and during the immediate post discharge period (7 days) by June 2013. Background The SMOOTH programme included: Improving Pa6ent and Whaanau Welfare by
Ensuring accuracy and reliability of informa6on at discharge Providing tailored pa6ent and whaanau centred educa6on and empower
pa6ents to self manage medica6ons Coordina6on of 6mely access to discharge medicines Establishing a phone call follow up service within 7 days of discharge.
Collabora6ng with other health professionals within Coun6es Manukau District Health Board (CMDHB) to
Improve the sa6sfac6on of stakeholders through more 6mely and accurate flow of informa6on regarding medicines and improving acute care demand management through a reduc6on in readmissions.
Last Updated 23 April 2012
20,000 Days C ampaig n
90% of high risk patients from adult
medical and surgical
wards will receive
medicine management services at discharge and post discharge (7days) by June 2013
High Risk Pt discharge
Discharge Planning Process
Medication Processes
Training Resources
Safer Medicines Outcomes on Transfer to Home –Driver Diagram
Processes –SOP/Checkli
st
Pt Identification
1° 2°
Identification of patients at greatest risk of harm and greatest potential for benefits
Change Concepts
Timing of discharge
Defined Process with Checklist
VHIU concept familiarisation
Specific Pharmacists dedicated to service
Use ART Tool to identify patients/cf other factors that may influence patient populations
Work of “Transitions of Care” group
Modify EDS template to identify high risk pts
Identification Process – Magnets on Pt boards (Enrol pts)
MR, Concerto, MUR training
Use of Checklist as prompt and to collect information
Specific Change Ideas
Pharmacist Resource
Recruitment
Coordination
Referral mechanism Accuracy of meds information at discharge
Access of meds
Meds Resource Pack
Med Rec on DischargeMed Review/EDS meds review
Fax script, access/transport, check testsafe if picked upIdentify barriers to access
Med card, PILs, Checklist, Compliance Aid
Medication Passport (mylist)
Communication
Follow up patient after d/c
Follow up significant issues with GP/comm pharm
Tools
Pharmacists with right skills
Learnings -‐ Phase 1 Small, inexpensive tests of change via Plan-‐Do-‐Study-‐Act cycles can provide
valuable return in overall learning Applying improvement science principles to these learning's will lead to
mul6ple system refinements Achievements
Successful tes6ng and development of a change package to deliver at discharge
Preven6on of 447 medica6on related errors -‐ 134 errors were graded as having the poten6al to result in rehospitalisa6on
Es6mated financial savings for CMDHB $291,696 per annum. Cumula6ve bed days saved is 582 days Funding secured to spread and implement package in Phase 2
Driver Diagram
Ideal to be SMOOTH discharge process
SM
OO
TH
phar
mac
yC
linic
al
Pha
rmac
yA
llied
Hea
lthN
ursi
ngM
edic
al S
taff
Pat
ient
SMOOTH magnet/sticker used to
make HR pt visible
EDS started
Admission Med Rec
Calls SMOOTH team
Patient goes home
EDS completed
SMOOTH statement in EDS
SMOOTH team informed of discharge
Contact community
pharmacy/primary care
HR Pt identified in ART
Prints HR list
EDD allocated to patient entered on
WiMs and/or whiteboard
SMOOTHs the patient
Patient in Hospital
MDT sign off of patient for
discharge/decision made
Discharge med rec
Telephone follow up post discharge
if appropriate
SMOOTH discharge process map
Results
Unintended Discrepencies Identified by SMOOTH
149
164
122
11
10
20
40
60
80
100
120
140
160
180
Grade ONE Grade TWO Grade THREE Grade FOUR Grade FIVE
Grade
Num
ber o
f Err
ors
Grade Descrip6on 5 An error that resulted in SERIOUS/CATASTROPHIC HARM to
patient.
4 An error that resulted in MAJOR HARM to patient. Major harm is that requiring increased hospital stay or significant morbidity.
3 An error that resulted in MODERATE HARM to patient. Moderate harm is that requiring treatment with another drug OR cancellation/postponement of
2 An error that resulted in MINOR HARM to patient. Minor harm is that requiring minor (non-drug) treatment or treatment change.
1 No harm or only minor harm – not requiring “treatment”
Grading of errors (Using Epifany® Grading System)
From 447 medica6on errors 134 errors were graded as having the poten6al to result in rehospitalisa6on
“Ideally I wish everyone would have SMOOTH discharge planning because in terms of the discharge they really are a warrant of fitness for the patient before they leave”
Dr Suluama Fuimaono-Sapolu (House Officer)
“It was really helpful when they (SMOOTH) came in and explained every one of the pills I have…..the medication side of it is actually falling into place”
Agnes Marshall (Patient)
A safer journey from hospital to home
SMOOTH Safer Medica:on Outcomes On
Transfer Home Aim The aim of the SMOOTH Programme is to reduce medica6on related readmissions by providing 90% of high risk adult medical and surgical pa6ents with a medica6on management service at discharge and during the immediate post discharge period (7 days) by June 2013. Background The SMOOTH programme included: Improving Pa6ent and Whaanau Welfare by
Ensuring accuracy and reliability of informa6on at discharge Providing tailored pa6ent and whaanau centred educa6on and empower
pa6ents to self manage medica6ons Coordina6on of 6mely access to discharge medicines Establishing a phone call follow up service within 7 days of discharge.
Collabora6ng with other health professionals within Coun6es Manukau District Health Board (CMDHB) to
Improve the sa6sfac6on of stakeholders through more 6mely and accurate flow of informa6on regarding medicines and improving acute care demand management through a reduc6on in readmissions.
Last Updated 23 April 2012
20,000 Days C ampaig n
90% of high risk patients from adult
medical and surgical
wards will receive
medicine management services at discharge and post discharge (7days) by June 2013
High Risk Pt discharge
Discharge Planning Process
Medication Processes
Training Resources
Safer Medicines Outcomes on Transfer to Home –Driver Diagram
Processes –SOP/Checkli
st
Pt Identification
1° 2°
Identification of patients at greatest risk of harm and greatest potential for benefits
Change Concepts
Timing of discharge
Defined Process with Checklist
VHIU concept familiarisation
Specific Pharmacists dedicated to service
Use ART Tool to identify patients/cf other factors that may influence patient populations
Work of “Transitions of Care” group
Modify EDS template to identify high risk pts
Identification Process – Magnets on Pt boards (Enrol pts)
MR, Concerto, MUR training
Use of Checklist as prompt and to collect information
Specific Change Ideas
Pharmacist Resource
Recruitment
Coordination
Referral mechanism Accuracy of meds information at discharge
Access of meds
Meds Resource Pack
Med Rec on DischargeMed Review/EDS meds review
Fax script, access/transport, check testsafe if picked upIdentify barriers to access
Med card, PILs, Checklist, Compliance Aid
Medication Passport (mylist)
Communication
Follow up patient after d/c
Follow up significant issues with GP/comm pharm
Tools
Pharmacists with right skills
Learnings -‐ Phase 1 Small, inexpensive tests of change via Plan-‐Do-‐Study-‐Act cycles can provide
valuable return in overall learning Applying improvement science principles to these learning's will lead to
mul6ple system refinements Achievements
Successful tes6ng and development of a change package to deliver at discharge
Preven6on of 447 medica6on related errors -‐ 134 errors were graded as having the poten6al to result in rehospitalisa6on
Es6mated financial savings for CMDHB $291,696 per annum. Cumula6ve bed days saved is 582 days Funding secured to spread and implement package in Phase 2
Driver Diagram
Ideal to be SMOOTH discharge process
SM
OO
TH
phar
mac
yC
linic
al
Pha
rmac
yA
llied
Hea
lthN
ursi
ngM
edic
al S
taff
Pat
ient
SMOOTH magnet/sticker used to
make HR pt visible
EDS started
Admission Med Rec
Calls SMOOTH team
Patient goes home
EDS completed
SMOOTH statement in EDS
SMOOTH team informed of discharge
Contact community
pharmacy/primary care
HR Pt identified in ART
Prints HR list
EDD allocated to patient entered on
WiMs and/or whiteboard
SMOOTHs the patient
Patient in Hospital
MDT sign off of patient for
discharge/decision made
Discharge med rec
Telephone follow up post discharge
if appropriate
SMOOTH discharge process map
Results
Unintended Discrepencies Identified by SMOOTH
149
164
122
11
10
20
40
60
80
100
120
140
160
180
Grade ONE Grade TWO Grade THREE Grade FOUR Grade FIVE
Grade
Num
ber o
f Err
ors
Grade Descrip6on 5 An error that resulted in SERIOUS/CATASTROPHIC HARM to
patient.
4 An error that resulted in MAJOR HARM to patient. Major harm is that requiring increased hospital stay or significant morbidity.
3 An error that resulted in MODERATE HARM to patient. Moderate harm is that requiring treatment with another drug OR cancellation/postponement of
2 An error that resulted in MINOR HARM to patient. Minor harm is that requiring minor (non-drug) treatment or treatment change.
1 No harm or only minor harm – not requiring “treatment”
Grading of errors (Using Epifany® Grading System)
From 447 medica6on errors 134 errors were graded as having the poten6al to result in rehospitalisa6on
“Ideally I wish everyone would have SMOOTH discharge planning because in terms of the discharge they really are a warrant of fitness for the patient before they leave”
Dr Suluama Fuimaono-Sapolu (House Officer)
“It was really helpful when they (SMOOTH) came in and explained every one of the pills I have…..the medication side of it is actually falling into place”
Agnes Marshall (Patient)
Our Aim:To reduce medication related
readmissions by providing 90% of high risk adult medical
and surgical patients with a medication management
service at discharge and during the immediate post discharge
period (7 days) by June 2013.
“It was really helpful when they (SMOOTH) came in and explained every one of the pills I have…..the medication side of it is actually falling into place” Agnes Marshall (Patient)
“Ideally I wish everyone would have SMOOTH discharge planning because in terms of the discharge they really are a warrant of fitness for the patient before they leave”
Dr Suluama Fuimaono-Sapolu (House Officer)
A safer journey from hospital to home
SMOOTH Safer Medica:on Outcomes On
Transfer Home Aim The aim of the SMOOTH Programme is to reduce medica6on related readmissions by providing 90% of high risk adult medical and surgical pa6ents with a medica6on management service at discharge and during the immediate post discharge period (7 days) by June 2013. Background The SMOOTH programme included: Improving Pa6ent and Whaanau Welfare by
Ensuring accuracy and reliability of informa6on at discharge Providing tailored pa6ent and whaanau centred educa6on and empower
pa6ents to self manage medica6ons Coordina6on of 6mely access to discharge medicines Establishing a phone call follow up service within 7 days of discharge.
Collabora6ng with other health professionals within Coun6es Manukau District Health Board (CMDHB) to
Improve the sa6sfac6on of stakeholders through more 6mely and accurate flow of informa6on regarding medicines and improving acute care demand management through a reduc6on in readmissions.
Last Updated 23 April 2012
20,000 Days C ampaig n
90% of high risk patients from adult
medical and surgical
wards will receive
medicine management services at discharge and post discharge (7days) by June 2013
High Risk Pt discharge
Discharge Planning Process
Medication Processes
Training Resources
Safer Medicines Outcomes on Transfer to Home –Driver Diagram
Processes –SOP/Checkli
st
Pt Identification
1° 2°
Identification of patients at greatest risk of harm and greatest potential for benefits
Change Concepts
Timing of discharge
Defined Process with Checklist
VHIU concept familiarisation
Specific Pharmacists dedicated to service
Use ART Tool to identify patients/cf other factors that may influence patient populations
Work of “Transitions of Care” group
Modify EDS template to identify high risk pts
Identification Process – Magnets on Pt boards (Enrol pts)
MR, Concerto, MUR training
Use of Checklist as prompt and to collect information
Specific Change Ideas
Pharmacist Resource
Recruitment
Coordination
Referral mechanism Accuracy of meds information at discharge
Access of meds
Meds Resource Pack
Med Rec on DischargeMed Review/EDS meds review
Fax script, access/transport, check testsafe if picked upIdentify barriers to access
Med card, PILs, Checklist, Compliance Aid
Medication Passport (mylist)
Communication
Follow up patient after d/c
Follow up significant issues with GP/comm pharm
Tools
Pharmacists with right skills
Learnings -‐ Phase 1 Small, inexpensive tests of change via Plan-‐Do-‐Study-‐Act cycles can provide
valuable return in overall learning Applying improvement science principles to these learning's will lead to
mul6ple system refinements Achievements
Successful tes6ng and development of a change package to deliver at discharge
Preven6on of 447 medica6on related errors -‐ 134 errors were graded as having the poten6al to result in rehospitalisa6on
Es6mated financial savings for CMDHB $291,696 per annum. Cumula6ve bed days saved is 582 days Funding secured to spread and implement package in Phase 2
Driver Diagram
Ideal to be SMOOTH discharge process
SM
OO
TH
phar
mac
yC
linic
al
Pha
rmac
yA
llied
Hea
lthN
ursi
ngM
edic
al S
taff
Pat
ient
SMOOTH magnet/sticker used to
make HR pt visible
EDS started
Admission Med Rec
Calls SMOOTH team
Patient goes home
EDS completed
SMOOTH statement in EDS
SMOOTH team informed of discharge
Contact community
pharmacy/primary care
HR Pt identified in ART
Prints HR list
EDD allocated to patient entered on
WiMs and/or whiteboard
SMOOTHs the patient
Patient in Hospital
MDT sign off of patient for
discharge/decision made
Discharge med rec
Telephone follow up post discharge
if appropriate
SMOOTH discharge process map
Results
Unintended Discrepencies Identified by SMOOTH
149
164
122
11
10
20
40
60
80
100
120
140
160
180
Grade ONE Grade TWO Grade THREE Grade FOUR Grade FIVE
Grade
Num
ber o
f Err
ors
Grade Descrip6on 5 An error that resulted in SERIOUS/CATASTROPHIC HARM to
patient.
4 An error that resulted in MAJOR HARM to patient. Major harm is that requiring increased hospital stay or significant morbidity.
3 An error that resulted in MODERATE HARM to patient. Moderate harm is that requiring treatment with another drug OR cancellation/postponement of
2 An error that resulted in MINOR HARM to patient. Minor harm is that requiring minor (non-drug) treatment or treatment change.
1 No harm or only minor harm – not requiring “treatment”
Grading of errors (Using Epifany® Grading System)
From 447 medica6on errors 134 errors were graded as having the poten6al to result in rehospitalisa6on
“Ideally I wish everyone would have SMOOTH discharge planning because in terms of the discharge they really are a warrant of fitness for the patient before they leave”
Dr Suluama Fuimaono-Sapolu (House Officer)
“It was really helpful when they (SMOOTH) came in and explained every one of the pills I have…..the medication side of it is actually falling into place”
Agnes Marshall (Patient)
Driver Diagram
Learnings - Phase 1• Small, inexpensive tests of change via Plan-Do-Study-Act cycles can provide valuable returns in overall learning• Applying improvement science principles to these learnings will lead to multiple system refinements
A safer journey from hospital to home
SMOOTH Safer Medica:on Outcomes On
Transfer Home Aim The aim of the SMOOTH Programme is to reduce medica6on related readmissions by providing 90% of high risk adult medical and surgical pa6ents with a medica6on management service at discharge and during the immediate post discharge period (7 days) by June 2013. Background The SMOOTH programme included: Improving Pa6ent and Whaanau Welfare by
Ensuring accuracy and reliability of informa6on at discharge Providing tailored pa6ent and whaanau centred educa6on and empower
pa6ents to self manage medica6ons Coordina6on of 6mely access to discharge medicines Establishing a phone call follow up service within 7 days of discharge.
Collabora6ng with other health professionals within Coun6es Manukau District Health Board (CMDHB) to
Improve the sa6sfac6on of stakeholders through more 6mely and accurate flow of informa6on regarding medicines and improving acute care demand management through a reduc6on in readmissions.
Last Updated 23 April 2012
20,000 Days C ampaig n
90% of high risk patients from adult
medical and surgical
wards will receive
medicine management services at discharge and post discharge (7days) by June 2013
High Risk Pt discharge
Discharge Planning Process
Medication Processes
Training Resources
Safer Medicines Outcomes on Transfer to Home –Driver Diagram
Processes –SOP/Checkli
st
Pt Identification
1° 2°
Identification of patients at greatest risk of harm and greatest potential for benefits
Change Concepts
Timing of discharge
Defined Process with Checklist
VHIU concept familiarisation
Specific Pharmacists dedicated to service
Use ART Tool to identify patients/cf other factors that may influence patient populations
Work of “Transitions of Care” group
Modify EDS template to identify high risk pts
Identification Process – Magnets on Pt boards (Enrol pts)
MR, Concerto, MUR training
Use of Checklist as prompt and to collect information
Specific Change Ideas
Pharmacist Resource
Recruitment
Coordination
Referral mechanism Accuracy of meds information at discharge
Access of meds
Meds Resource Pack
Med Rec on DischargeMed Review/EDS meds review
Fax script, access/transport, check testsafe if picked upIdentify barriers to access
Med card, PILs, Checklist, Compliance Aid
Medication Passport (mylist)
Communication
Follow up patient after d/c
Follow up significant issues with GP/comm pharm
Tools
Pharmacists with right skills
Learnings -‐ Phase 1 Small, inexpensive tests of change via Plan-‐Do-‐Study-‐Act cycles can provide
valuable return in overall learning Applying improvement science principles to these learning's will lead to
mul6ple system refinements Achievements
Successful tes6ng and development of a change package to deliver at discharge
Preven6on of 447 medica6on related errors -‐ 134 errors were graded as having the poten6al to result in rehospitalisa6on
Es6mated financial savings for CMDHB $291,696 per annum. Cumula6ve bed days saved is 582 days Funding secured to spread and implement package in Phase 2
Driver Diagram
Ideal to be SMOOTH discharge process
SMO
OTH
ph
arm
acy
Clin
ical
Ph
arm
acy
Allie
d H
ealth
Nur
sing
Med
ical
Sta
ffPa
tient
SMOOTH magnet/sticker used to
make HR pt visible
EDS started
Admission Med Rec
Calls SMOOTH team
Patient goes home
EDS completed
SMOOTH statement in EDS
SMOOTH team informed of discharge
Contact community
pharmacy/primary care
HR Pt identified in ART
Prints HR list
EDD allocated to patient entered on
WiMs and/or whiteboard
SMOOTHs the patient
Patient in Hospital
MDT sign off of patient for
discharge/decision made
Discharge med rec
Telephone follow up post discharge
if appropriate
SMOOTH discharge process map
Results
Unintended Discrepencies Identified by SMOOTH
149
164
122
11
10
20
40
60
80
100
120
140
160
180
Grade ONE Grade TWO Grade THREE Grade FOUR Grade FIVE
Grade
Num
ber o
f Err
ors
Grade Descrip6on 5 An error that resulted in SERIOUS/CATASTROPHIC HARM to
patient.
4 An error that resulted in MAJOR HARM to patient. Major harm is that requiring increased hospital stay or significant morbidity.
3 An error that resulted in MODERATE HARM to patient. Moderate harm is that requiring treatment with another drug OR cancellation/postponement of
2 An error that resulted in MINOR HARM to patient. Minor harm is that requiring minor (non-drug) treatment or treatment change.
1 No harm or only minor harm – not requiring “treatment”
Grading of errors (Using Epifany® Grading System)
From 447 medica6on errors 134 errors were graded as having the poten6al to result in rehospitalisa6on
“Ideally I wish everyone would have SMOOTH discharge planning because in terms of the discharge they really are a warrant of fitness for the patient before they leave”
Dr Suluama Fuimaono-Sapolu (House Officer)
“It was really helpful when they (SMOOTH) came in and explained every one of the pills I have…..the medication side of it is actually falling into place”
Agnes Marshall (Patient)
A safer journey from hospital to home
SMOOTH Safer Medica:on Outcomes On
Transfer Home Aim The aim of the SMOOTH Programme is to reduce medica6on related readmissions by providing 90% of high risk adult medical and surgical pa6ents with a medica6on management service at discharge and during the immediate post discharge period (7 days) by June 2013. Background The SMOOTH programme included: Improving Pa6ent and Whaanau Welfare by
Ensuring accuracy and reliability of informa6on at discharge Providing tailored pa6ent and whaanau centred educa6on and empower
pa6ents to self manage medica6ons Coordina6on of 6mely access to discharge medicines Establishing a phone call follow up service within 7 days of discharge.
Collabora6ng with other health professionals within Coun6es Manukau District Health Board (CMDHB) to
Improve the sa6sfac6on of stakeholders through more 6mely and accurate flow of informa6on regarding medicines and improving acute care demand management through a reduc6on in readmissions.
Last Updated 23 April 2012
20,000 Days C ampaig n
90% of high risk patients from adult
medical and surgical
wards will receive
medicine management services at discharge and post discharge (7days) by June 2013
High Risk Pt discharge
Discharge Planning Process
Medication Processes
Training Resources
Safer Medicines Outcomes on Transfer to Home –Driver Diagram
Processes –SOP/Checkli
st
Pt Identification
1° 2°
Identification of patients at greatest risk of harm and greatest potential for benefits
Change Concepts
Timing of discharge
Defined Process with Checklist
VHIU concept familiarisation
Specific Pharmacists dedicated to service
Use ART Tool to identify patients/cf other factors that may influence patient populations
Work of “Transitions of Care” group
Modify EDS template to identify high risk pts
Identification Process – Magnets on Pt boards (Enrol pts)
MR, Concerto, MUR training
Use of Checklist as prompt and to collect information
Specific Change Ideas
Pharmacist Resource
Recruitment
Coordination
Referral mechanism Accuracy of meds information at discharge
Access of meds
Meds Resource Pack
Med Rec on DischargeMed Review/EDS meds review
Fax script, access/transport, check testsafe if picked upIdentify barriers to access
Med card, PILs, Checklist, Compliance Aid
Medication Passport (mylist)
Communication
Follow up patient after d/c
Follow up significant issues with GP/comm pharm
Tools
Pharmacists with right skills
Learnings -‐ Phase 1 Small, inexpensive tests of change via Plan-‐Do-‐Study-‐Act cycles can provide
valuable return in overall learning Applying improvement science principles to these learning's will lead to
mul6ple system refinements Achievements
Successful tes6ng and development of a change package to deliver at discharge
Preven6on of 447 medica6on related errors -‐ 134 errors were graded as having the poten6al to result in rehospitalisa6on
Es6mated financial savings for CMDHB $291,696 per annum. Cumula6ve bed days saved is 582 days Funding secured to spread and implement package in Phase 2
Driver Diagram
Ideal to be SMOOTH discharge process
SMO
OTH
ph
arm
acy
Clin
ical
Ph
arm
acy
Allie
d H
ealth
Nur
sing
Med
ical
Sta
ffPa
tient
SMOOTH magnet/sticker used to
make HR pt visible
EDS started
Admission Med Rec
Calls SMOOTH team
Patient goes home
EDS completed
SMOOTH statement in EDS
SMOOTH team informed of discharge
Contact community
pharmacy/primary care
HR Pt identified in ART
Prints HR list
EDD allocated to patient entered on
WiMs and/or whiteboard
SMOOTHs the patient
Patient in Hospital
MDT sign off of patient for
discharge/decision made
Discharge med rec
Telephone follow up post discharge
if appropriate
SMOOTH discharge process map
Results
Unintended Discrepencies Identified by SMOOTH
149
164
122
11
10
20
40
60
80
100
120
140
160
180
Grade ONE Grade TWO Grade THREE Grade FOUR Grade FIVE
Grade
Num
ber o
f Err
ors
Grade Descrip6on 5 An error that resulted in SERIOUS/CATASTROPHIC HARM to
patient.
4 An error that resulted in MAJOR HARM to patient. Major harm is that requiring increased hospital stay or significant morbidity.
3 An error that resulted in MODERATE HARM to patient. Moderate harm is that requiring treatment with another drug OR cancellation/postponement of
2 An error that resulted in MINOR HARM to patient. Minor harm is that requiring minor (non-drug) treatment or treatment change.
1 No harm or only minor harm – not requiring “treatment”
Grading of errors (Using Epifany® Grading System)
From 447 medica6on errors 134 errors were graded as having the poten6al to result in rehospitalisa6on
“Ideally I wish everyone would have SMOOTH discharge planning because in terms of the discharge they really are a warrant of fitness for the patient before they leave”
Dr Suluama Fuimaono-Sapolu (House Officer)
“It was really helpful when they (SMOOTH) came in and explained every one of the pills I have…..the medication side of it is actually falling into place”
Agnes Marshall (Patient)
From 526 medication errors, 174 errors were graded as having the potential to result in rehospitalisation
Preliminary Results
Collaborative Team:Clinical Lead: Sanjoy Nand Team: Rebecca Lawn (Team Lead), Ahmed Marmoush, Doreen Liow, Ian Kaihe-Wetting, Karla Rika-Heke, Nazanin Falconer, Sonia Varma, Nisha Bangs, Truc Nguyen, Monique Davies and Ian Hutchby
Achievements:• Improved patient and whaanau (family) welfare• Increased collaboration between health professionals• Service provided to 764 patients, 526 errors identified and prevented, 174 of which could have negatively impacted on length of stay• Estimated cost savings of $220,000 per annum• 2013 Counties Manukau Science Fest & Health Excellence Awards: Winner of the Allied Health Category and overall winner Science Fest and Health Excellence Awards