Download Case Study 2 Ruth Brown - KCHFT Omitted dose

Reducing Omitted Doses
through Audit
Ruth Brown
Quality and Governance Pharmacist
Kent Community NHS Foundation Trust
[email protected]
Introduction
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Describe Kent Community Health NHS
Foundation Trust
Present the development of an omitted dose
audit
Present a brief summary of the findings from five
years of collecting audit data.
Kent Community NHS Health Foundation Trust
Kent Community NHS Foundation Trust (KCHFT) serves a
population of 1.4 million across Kent, and 600,000 in East
Sussex and London with a staff of 5,000.
We provide wide-ranging NHS care for people in the
community, in a range of settings including people’s own
homes; nursing homes; health clinics; community hospitals;
minor injury units and in mobile units.
Background
NPSA Rapid Response Alert 2010- Reducing harm
from omitted and delayed medicines in hospital
In response an omitted dose audit was designed and conducted in 2011
in 12 community hospitals across Kent.
Audit Aims:
• to ascertain current medication omission rates
• to ensure appropriate action is taken subsequent to incidents
• to encourage incident reporting related to omission or delay
• to reduce harm from omitted and delayed medicines.
Methodology 2011
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All pharmacy staff working in community hospitals
collected the data from all charts from each ward.
14 days medicines administrations were checked for
each patient.
Omitted dose rate calculated from total administrations
that should have been given.
Risk of harm calculated from UKMi critical medicines list
(2010, revised in 2016)
Methodology 2011
• Assessing risk of harm using UKMi definitions
Low risk: Nil or negligible patient impact with nil or minor
intervention required; no increase in length of stay.
Moderate risk: Significant short-term patient impact with moderate
intervention required; increase in length of hospital stay possible.
Significant risk: Significant or catastrophic long-term patient impact
with ongoing intervention required; long increase in length of stay
possible.
2011 Findings
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Omitted dose rate was 1.76% with and without codes
Problems with lack of consistency of drug chart omission
codes and lack of consistency with multiple staff
collecting data
Nursing staff lack of knowledge regarding critical
medicines
Good practice noted to be reviewing the drug charts after
the medicine rounds in some wards with low omitted dose
rates
Target setting in 2011
The initial omitted dose rate targets in 2011 were set at:Target: The omission rate for medication omissions (with and without codes) for
a Community Hospital Ward to be less than 1.5 %
Target: The omission rate for medication omissions (without codes) for
Community Hospital Ward to be less than 1.0%
Target: The omission rate for medication omissions (with and without codes) in
a Community Hospital where the risk is significant to the patient to be less
than 0.5%
Methodology changes since 2011
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One pharmacist responsible for data collection each year
Targets changed to 0% omitted dose i.e. zero tolerance.
A hard line was taken.
Target: 100% peer checking
Omitted dose by risk
Percentage of risk errors from omitted doses
The percentage of ‘significant risk’ errors:
0.25% in 2013
0.11% in 2014
0.21% in 2015. Increase
The percentage of ‘moderate risk’ error:
0.24% in 2013
0.12% in 2014
0.10% in 2015 Decrease
The percentage of ‘low risk’ error:
0.92% in 2013
0.94% in 2014
0.46% in 2015 Decrease
Quality Improvement
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Drug chart standardised across the whole trust
Medicine charts reviewed after drug rounds adopted as good practice for all
wards. Peer checking form introduced in 2013 to aid nursing staff with the
process. Significant increase in peer checking shown in 2015 with almost
half the wards peer checking 90-100% of the time and the rest 50-90% of the
time.
Management of staff with responsibility/ accountability emphasised
Datix reporting encouraged
Twice daily delivery requested in tender specification for new supplier of
medicines to hospitals
Quality Improvement
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Low molecular weight heparins given once a day at the same time each day.
Parkinson’s patients are treated separately with additional reminders for
nursing staff to administer medicines, for example, mobile phone alarms.
Weekly alendronic acid is administered by night staff before breakfast.
Process put in place to make sure that patients who are off the ward (for
example, renal dialysis) still receive their medication.
An agency nurse leaflet has been introduced to convey important information
around medicines.
Omitted dose rate 2011 – 2015
Thank you!
For further information contact:
[email protected]