Shared learning database

Steve Turner Innovations Community Interest Company
Published date:
February 2014

A child centered project, (led by the parents), to improve medicines safety for children, through the implementation of robust medicines reconciliation and a parent held medicines record. The project commenced in community paediatrics, aimed at children with complex conditions, and at the end of life. It has begun to link primary care, community care, schools, social care, secondary care and tertiary care.

The project has helped deliver recommendations of the NICE guidance on managing medicines in care homes (SC1 recommendation 1.7 & CG76) by introducing a 'medicine reconciliation' process in short break houses, and sharing this across the pathway when children transfer between care settings. The new record is kept accurate and up to date on each contact with the participating services. It has stimulated increased reporting of medicines related problems, and promoted resolution across the health community.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

- Reducing the risks of error, by providing full and accurate information on children's medicines across their entire pathway, in an accessible format, in real-time.
- Cutting out need for parents to keep repeating what medicines children are taking to different professionals and care agencies.
- Cutting out the need for parents to chase prescription information.
- Freeing up medical and clinical time spent by staff chasing information. Allowing more time to spend with the children.
- Ensuring that the information on a child's medicine such as when to take it, how to take it, when to alter the dose etc. is always legible, unambiguous, complete and easily available to all who require it.
- Working to a long term goal of totally eliminating the need for children's medicines to be written down in different places by different people (transcribing), and the associated risks of error.
- Reducing the number of third party handovers of prescribing information, between clinicians, and with parents.

Reasons for implementing your project

The project is aimed at children with complex needs and at end of life. This may include enteral feeds; ventilation; TPN; epilepsy; complex and rapidly changing medicine regimes and complex titration regimes. It is not unusual to be prescribed 10+ regular medicines and 15+ as required/prn medicines (a 28 page medicines chart is possible). The child's pathway has prescribers in the acute trust and a nurse led community services (no doctors of prescribers). These children access a variety of services including Inpatient Services, Tertiary Centres, Community Paediatricians, GPs, Community Pharmacies, Specialist Nurses, Children's Community Nurses and Diana Nurses, Short Break Houses, Home Care Services and Special Schools. It is not unusual for a child to be under the care of 5 different providers. Many services set up in this way (Terry & Sinclair 2012). Prior to this work there was no formally agreed structure or process to coordinate the management of medicines across services for children, either locally and (we believe) nationally. Additionally multiple IT systems are involved and, in the pilot area and beyond, none of these talk to each other. As a result parents have to repeat information on medicines many times. This lack of a single real-time profile of all medicines children are taking results in a high level of risk of a serious medicines errors and near misses. In order to manage this, staff across the services waste clinical time through duplication effort, as medicines and prescribing information can be held in as many as 6 different places. This also leads to a risk of other errors because of the time spent chasing information which should be readily to hand.

Baseline assessment:
The audit asked 5 questions, arrived at in focus group type settings:
1. When my child's medicines are changed the information (e.g. discharge letter, clinic letter) reaches his/her GP quickly.
2. I have to repeat information about what medicines my child is taking to health professionals clinics; surgeries; hospitals etc.
3. I have enough information on my child's medicines (e.g. what they are for, potential side-effects and interactions, how to store and administer the medicine).
4. Once prescribed, it is easy to obtain an initial and repeat supply of my child's medicines.
5. I am confident in the organisation of services for my child's medicines.

We also looked at incident and near miss reports, complaints and plaudits.

How did you implement the project

The project started as a small piece of work to implement a better medicines process in Children's Short Break Houses. It changed as a result of parents' requests. When the reference group saw the medicine chart produced in the short break houses they asked "why can't we carry this round with our child, so that when they see a doctor the doctor can write changes directly on it" Because we are using an action learning approach to the project, we were able to test this using the PDSA approach.

In carrying out a review for the project development we:
- Spent time identifying and linking with stakeholders and potential stakeholders both locally and nationally. (Our My Medicines chart is partly based on a project carried out by NHS Norfolk).
- Linked with specialist services and other providers and clinical networks, including the South West Paediatric Palliative Care Network, the South West Strategic Clinical Network, the Neonatal and Paediatric Pharmacists Group, and the Association of Chief Children's Nurses.
- Linked with the IHI and NICE Medicines and Prescribing Centre Team.
- Took advice from the Cornwall Parent and Carer Council.
- Linked with the CQC and Ofsted.
- Asked questions and participated in discussions on social media.
- Carried out a literature search using key words 'children' 'paediatrics' medicines'; 'prescribing'.
We believe this project is innovative because:
1. The project it is 'owned' by the service users and effectively designed by parents and carers.
2. It involved robust stakeholder mapping at the outset, with a plan for appropriate involvement of each stakeholder.
3. The project is based on the child's pathway rather than the services of a single provider.
4. Inter organisational / inter-disciplinary communication and cooperation has been facilitated by a lead organisation outside the service providers. (Effectively the problem was contracted out to a third party). This has resulted in reduced bureaucracy and faster implementation.

It has also prevented problems around organisational ownership of the project as the chart we initially produced was not linked to any provider and became the property of the parents. This also means that we have been able to bring in relevant experts (normally Associates of the Community Interest Company) for shorter periods of time, drawing on wider pool of expertise.

Key findings

Results to date:
The My Medicines project has resulted in 40 children with complex conditions being offered a hand held paper record of their medicines (produced and validated by clinicians), which they take around with them wherever they go. The My Medicines pilot has proven safety benefits, including probable prevention of serious medicines incidents and promotion of linked governance.

Benefits to date:
Key safety benefits are that:
The previous process
- Didn't involve child's GP
- Didn't ask parents to check and sign the chart
- Led to many 'workarounds' for problems
- Was used in Short Break Houses only

The My Medicines process involves the child's own GP; has to be signed and checked by the parents, has eliminated workarounds and is used across the child's pathway. This has been evidenced by an audit of parent's views; local audits of the charts and an increase in medicines incident and near miss reporting. In the first month we raised 17 medicines near misses. Of these 11 related to problems with communication of information across the child's pathway. This has resulted in improved communication and engagement between different clinical groups and providers, and a desire from all quarters to take the project further.

Key learning points

Key learning points include:
- Prior to the My Medicines project there was no system of medicines management across the child's pathway, so parents had to repeat information on medicines many times.

- Medicines reconciliation was not robust, creating scope for error. In fact robust / formal medicines reconciliation was not carried out in any setting locally. (This we believe is a national problem).

- This project has enabled us to justify a post for Paediatric Community Pharmacist, and recruit to this post.

- Staff in various organisations no longer have to chase information, or work on incomplete information. When this happens we raise and incident.

- Prior to this project it was not uncommon for prescriber's instructions to be untraceable, or for us to be unsure if we had a copy of the most relevant / latest clinic letter.

- The level of medicines incidents and near misses has increased since our new checking processes were put in place, and they are followed through.

- Where prescribing best practice standards and GMC prescribing guidelines are not met we now raise an incident,and this is beginning to be tracked across the relevant organisations (being taken forward at the Area Prescribing Committee).

- Medicines management learning and competency assessments are not standard across all providers, so for example many organisations reinvent the wheel.

- Most providers use non-registered staff administer to medicines to thsi client group in the community and processes for ensuring the safety of this are unacceptably variable.

Contact details

Steve Turner
Managing Director
Steve Turner Innovations Community Interest Company

Is the example industry-sponsored in any way?

This project was commissioned by Cornwall Partnership NHS Foundation Trust and delivered by Steve Turner Innovations Community Interest Company. Steve Turner is a NICE Medicines and Prescribing Centre Associate.