Making Medication Administration Safer: A Resilience Approach C Alice Oborne PhD, Consultant Pharmacist in Medication Safety and Trust Medication Safety Officer Amelia Samuel, Senior QIPS Manager for Medical Specialties Resilience in Healthcare Masterclass 7-8 May 2015. Guy s
Objectives Outline application of principles of resilience in understanding medication safety to prevent dose omissions Illustrate with work around timely medication doses for inpatients (provisional data) 2
Traditional Approach to Quality Improvement and Safety Reactive learning from local, national data 1. Investigation of reported incidents Including Root Cause Analysis 2. Trends in incidents, compare with similar sites 3. Complaints 4. Claims 5. Inquests, Coroner s reports 6. Patient feedback (PALs) 7. Clinical audit Prospective 8. Risk assessments (potential to cause harm) 9. Failure Mode and Effects Analysis Learning when things go wrong locally and externally Action planning, test interventions Spread 3
Omitted or Delayed Medication Doses Nationally: 16% medication incidents reported due to omission or delay 1 Locally: 23% due to omission or delay (901/4003) Greater risk with specific medicines Insulins, antimicrobials, anti-epileptic drugs, Parkinson s disease drugs 2 Omissions/delays All medication incidents 350 300 250 200 150 100 50 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 1 Reducing harm from omitted and delayed medicines in hospital NPSA/2010/RRR009. 2010. http://www.nrls.npsa.nhs.uk/alerts/?entryid45=66720 2 Trust Omitted or delayed doses: Critical drugs list 2014 2015 4
Protected data Incident data shows that antimicrobial and insulins omissions were most common drugs classes omitted 5
Protected data Drug administration was more common stage of reported incident, than prescribing and dispensing of medicines 6
Trust Omitted Doses Working Group Reviewed incident and audit data Multiple contributing factors: Complex and changing environment No drug in stock on the ward Unable to get hold of prescriber Incorrect documentation No drug in stock in pharmacy Lack of staff knowledge Distractions / interruptions 7
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Safety-I versus Safety-II Traditional Approach: Safety-I Resilience Approach: Safety-II A Blue Cheese Model? 9
New Safety Model Capacity Work as Imagined System / Organisation of work Standards Staffing Skill Mix Equipment Drug storage Demand (Variation in the environment) Low staffing levels Lack of equipment Interruptions Prescription omission Patient acuities and co-morbidities Work as Done Normal Performance Adjustments Physical cues / reminders Workarounds Escalation Patient prompts Acceptable Outcomes (successes) Administration of insulins and antimicrobials within 2 hours of time due Administration of antimicrobials within 1 hour during sepsis Adapted from Hollnagel, E (2012). A Tale of Two Safeties. Retrieved from http//www.resilienthealthcare.net; see also DNM Safety (2014) From Safety-I to Safety-II: A White Paper. Available at: http://www.shybrary.aero/bookshelf/books/2437.pdf Adapted from Anderson, J (2014). CARe Resilience Model, Centre for Applied Resilience in Healthcare (CARe). Available at: http://resiliencecentre.org.uk/fact-sheets/modelling-organisational-resilience/ 10
Methodology 1. Two wards: surgical and medical 2. Understand normal medicines procedures Interview ward manager and staff 3. Patients with insulin or antimicrobial due 4. Observation: changes in the environment (environmental variation) and how staff respond (performance adjustments) Discussion of observations with staff 11
Methodology (2) 5. Qualitative data analysis 6. Analysis iterative with data collection 7. Decide interventions by learning from the successes 8. Test changes 12
Pilot to date 1 Medical Ward at GSTT 1 afternoon (pilot) and 1 morning drug round 13
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Findings: Observation of Drug Rounds Work as Imagined Work as Done Capacity 6 beds per nurse Work in order of bed number Start drug round at dedicated time Protected time, no interruptions (red apron) Work independently Ask a member of the team for help (check IV & CD) Drugs & equipment stored in dedicated places Demand (Variation in the Environment) Dealing with other patient requests / needs Busyness / multitasking Drugs not stored in the usual place Unable to find equipment Helping another member of the team (e.g. checks) Broken equipment Mixed model of electronic and paper prescribing Fluctuation in staffing levels Performance Adjustments Previous shift administering meds Asking for help Well labelled alternative storage space for drugs Dedicated member of the nursing team with no patient load Mental note Visual cues (computer on wheels) Success Failure Lack of adjustments to higher patient acuities and heavy workload 15
Learning Some systems improvements were in place Heavy mental workload from interruptions Looking for medicines and equipment time consuming Teamwork Failures were seen when workload was not assessed and adjusted (2 hourly dressings, multiple drugs prescribed) 16
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Questions