Key to the role of a pharmacist, is medicines reconciliation at the interfaces of care (NICE NG5 recommendations 1.3.1, 1.3.2 &1.3.5). This involves aligning pre-admission medications against those prescribed in hospital using at least two sources, including the Electronic Care Record (ECR).
Prescribers are consulted to ensure errors are corrected and discrepancies resolved, which ultimately prevents patients from coming to harm. Changes are documented using the ECR proforma, thereby resulting in a complete list of medicines accurately communicated within the patient’s medical notes (NG5 recommendation 1.3.7).
The categorisation of errors identified during a baseline audit indicated that most could be attributed to inappropriate or incomplete medicines reconciliation by prescribers and an over-reliance on the ECR record as a single source. Relating the project to the strategic themes of Quality 2020, we aimed to transform the culture towards medicines reconciliation and engage a more multidisciplinary approach (recommendation 1.3.4).
Our co-authors were:
- Ms R Johnston (WHSCT Clinical Pharmacist)
- Mr B Skelly (Surgical Registrar)
- Mr Z Bali (Associate Specialist General Surgery)
- Mr A Gidwani (Consultant General Surgeon)
Aims & Objectives
Prescribing errors occur in 1-15% of medication written for hospital inpatients 1. The EQUIP study found that prescribing error rates for junior doctors are around 9%2. Errors made during drug prescription are the most common type of avoidable medication error, and are hence an important target for improvement3,4. Recognising vulnerabilities for errors, medicines reconciliation at interfaces of care has thus become an important recognised element of patient safety.
Locally an observed increase in the number of pharmacist interventions at admission and discharge and a concurrent series of ‘near miss’ events prompted the initiation of a Quality Improvement Project (QIP) to look at system improvements / Plan-Do-Study-Act (PDSA) cycles to improve the situation. This QIP aimed to address incomplete or inaccurate medicines reconciliation and to engage prescribers to ensure a more multi-disciplinary approach so as to improve medicine prescription practice. For motivational purposes a staggered reduction in the rate of prescription error per patient (relative to baseline) of 25% by the end of June 2015 and 50% by the end of July 2015 were agreed.
This QIP took place in a general surgical ward at Altnagelvin Area Hospital, L’Derry, Northern Ireland, between March – November 2015. Per annum there are approximately 1500 elective admissions to the ward. Prior to the project initiation there had been an observed number of pharmacist recommendations to prescribers to amend the kardex after completion and verification of a patient’s pre-admission medications (medicines reconciliation on admission). Concurrently there was also a series of ‘near-miss’ events involving critical medicines being omitted / prescribed incorrectly and thereby impacting on patient safety.
Identification and buy in from a surgical champion was initially achieved and a baseline audit undertaken. Results were categorised and resources focussed on the admission stage of the patient journey. After presentation at a lunchtime learning event it was agreed that to move the project forward International Healthcare Improvement (IHI) quality improvement methodology would be utilised to help adapt a multi-disciplinary approach to improve medicines accuracy on admission and thereby ensure that the kardex is a true and accurate reflection of the prescriber’s intentions.
Key to this would be pharmacists and prescribers working in collaboration to agree and introduce changes in a stepped manner with an appropriate measure to reflect the impact of these. Given that prescribing errors are largely preventable and are associated with pro-longed hospital stays and medication related hospital re-admissions, the project had significant potential to improve patient care and assist with patient flow.
A prospective baseline audit was undertaken from 9th-12th March 2015 inclusive, examining admission and discharge prescriptions for 73.5% of all patients on the ward during the allocated time period. The types of prescription error, stage of patient journey and prescriber grade were recorded with the key measure reported as the average error rate per patient.
Data indicated the highest incidence of errors occurred on admission, hence resources were targeted here as this should minimise the potential of medication inaccuracies being carried through to discharge. The results were fed back to a surgical champion and a multi-disciplinary brain storming session undertaken that explored the stages of the admission process and sought to identify where prescribing errors can occur and generate potential solutions to overcome these (Figure 1 in the supporting material). To move forward a driver diagram (Figure 2 in the supporting material) was developed and ‘buy in’ was achieved from all prescribers. Aligning the project to both the strategic goals (Figure 3 in the supporting material) and level 2 of the attributes framework of Quality 2020, which is a 10 year strategy designed to protect and improve quality in health and social care in Northern Ireland, the whole team were engaged in introducing a series of PDSA cycles and agreeing the measure. These enabled the project to be taken forward using small tests of change that were introduced and tested quickly.
Multiple cycles were utilised to refine and streamline the process, including printing of the Electronic Care Record (ECR) on admission by prescribers, multi-disciplinary education on the appropriate use of ECR and engagement with Surgical Consultants. An email group in addition to weekly ‘huddles’ was established to give feedback on progress and maintain momentum. Snap shot audits were undertaken focussing on two key measures – a process measure in the mean number of ECRs printed on admission by medical staff and an outcome measure in the mean number of prescribing errors per patient. A run chart of progress was plotted and emailed to prescribers each week.
While no costs were incurred, the biggest challenge faced was sustainability of champions and recruitment of a nursing champion due to long-term illness. To counter balance these at the switch over of medical staff in August 2015, a permanent staff grade was recruited as the surgical champion and subsequently the Lead Surgical Consultant and Lead Nurse Manager were both engaged more fully on a frequent basis.
Results and evaluation
Baseline data collection recorded 158 unintentional prescribing errors with the majority occurring on admission compared to discharge (4.38 per patient Vs 0.61 per patient). Focussing on the admission stage, PDSA cycles were introduced and their impact on reducing error rate is annotated in Figure 4 in the supporting material.
Errors reduced to 2.6 per patient subsequent to the change of practice in the admission process of printing the ECR (40.7% reduction from baseline), thereby achieving the target of 25% reduction relative to baseline by June 2015. However, with changeover of medical staff and the absence of ward based champions the error rate increased to 3.7 per patient, resulting in the July 2015 target of 50% from baseline not being met.
After the introduction of weekly huddles, training of prescribers and discussion with the Lead Surgical Consultant the error rate reduced to 1.3 per patient, equivalent to a 70.3% reduction from baseline (target 50%). Posters and the ‘ADMIT’ strategy were then launched which, while still below target, saw a small increase in overall error rate. To target all prescribers, including those who do not normally work in the project area, but who may participate in cover, the QIP was presented and discussed at Thursday lunchtime teaching. Subsequently errors were reduced to 1.08 per patient by 27th October and 0.8 per patient by 3rd November respectively (81.7% from baseline). A clear correlation was demonstrated between mean number of prescribing errors per patient (outcome measure) and printing of ECR on admission (process measure).
Key learning points
The switchover of medical staff and the absence of ward based champions had a significant impact on the error rate. It is therefore key to include training on induction for prescribers on ECR and medicines reconciliation. Furthermore, a surgical champion who is a permanent member of staff should counter balance the impact of medical rotations and help improve consistency of results. In addition results would have been more likely to be sustained had a systems approach been adapted with multiple areas undertaking the same QIP, rather than just an isolated clinical pocket. A systems bundle would potentially have negated the impact of the absence of champions as it would have been owned by the clinical team rather than individuals.
Weekly feedback in the form of emails and huddles gives support, encouragement and provides learning to the multi-disciplinary team. However, despite the nature of the information presented within the run chart in retrospect this would have potentially had a bigger impact and influencing role on medical, nursing and pharmacy colleagues had it been displayed within the clinical area rather than being disseminated via email.
IHI Improvement methodology is an effective tool to demonstrate how tests of change can improve processes. Key to success is having a specific aim that is both realistic and the impact of which can be observed in ‘real time’. This helps motivation and momentum and in the context of health care ultimately impacts on patient safety.
- Creation of a better medication safety culture in Europe: Building safe medication practices. Council of Europe Expert Group on Safe Medication Practices (2006).
- Dornan T, Ashcroft D, Heatherfield H, et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education: EQUIP study. London: General Medical Council; 2009
- Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995; 274: 35–43.
- Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995; 274: 29–34.