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Chance to Check

Karon Cormack Clinical Risk ManagerGreater Glasgow & Clyde Health Board

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Medication incidents

Interested in wrong patient incidents Violation of policy Theory regarding the reasons SPSP work – deliberate design vs hard

work and vigilance Chance to check concept

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Focus Groups

Medication errors and practice:

5 groups between 6 – 24 (12 ideal) Hardly any had been involved in a focus

group before Wary at first but soon talked freely Debated with each other Needed to be controlled without influencing Rich source of information

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Focus Groups - medication round

Not enough time Debate about who should do it Lost importance Feels very task driven Underlying concern

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Focus Groups – current practice

Admitted to not checking name band Admitted giving drug they are not

sure of Admitted not thinking about the

patient in relation to the drug Admitted problems with no

interruptions

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Focus Groups – name band

Feel they know the patient Embarrassment - as if nurse has

forgotten who the patient is Don’t want to disturb patient e.g. at

night Time Felt to be different from blood

transfusion

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Chance to Check - content

Identifying 4 key statements that must be self asked on each administration

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I know what this drug is

I think this when I am dispensing the drug into the medicine cup.

Chance to Check 1.

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Chance to Check 2.

This drug and dose is suitable for this patient

I think this when I have dispensed the medication and I am thinking of the patient I plan to give it to.

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Chance to Check 3.

The patient verbally confirms their name if possible

On approach to the patient I ask for confirmation of name.

“Hi Mr Brown, I have your medicines, tell me your full name please”

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Chance to Check 4.

The patient's name band matches the kardex

I check the patient’s name band with the name and DOB or CHI number on the kardex.

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Chance to Check - content

Identifying 4 key statements that must be self asked on each administration

Prompt cards can be used initially but should become automatic.

Every patient, every time deliberate design.

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Chance to Check – time / focus

Take the time to get the task right Do the right checks Acts like a pause in the process Raise awareness of medication issues Prompt ward discussion Standardising approach

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Additional Points – No interruptions

Signage On admission Communication book Agreement on acceptable

interruptions Be strong and united

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Additional Points - BNF

One on each trolley Up to date Labelled

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Post Round Sweep

Reduce errors relating to medicines; Omitted / forgotten / lost Taken late Taken by other patients

Your drug round – your responsibility.

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Promote ward discussion

When & Who? Incidents feedback Review Chance to Check Praise

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Implementation

Pilot wards Spread to other wards in S&A Taken to Heads of Nursing and spread

to other directorates Included in MyMeds project Recently introduced to 3rd year

undergraduates

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Results

Staff like it Feel they have permission to do the

right thing Feel they are using nursing

knowledge Feel more assured the process is

good Less interruptions

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Any Questions?