collation of resources to reduce the incidence of delayed ... · [email protected] sop: reducing...
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Winner: Dressings, PrescQIPP Innovation awards 2013; Winner: RPS Pharmaceutical Care award 2013 Finalist: HSJ Patient safety in primary care award 2013; Winner: UKCPA/Guild Conference Best Poster award 2013
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East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast
Medicines Use and Safety
Collation of Resources to Reduce the Incidence of Delayed and Omitted Medicines
Background In February 2010 the NPSA issued Rapid Response Report 009 Reducing Harm from omitted and delayed medicines in hospital1. It proposed a staged approach to defining locally agreed critical medicines and developing systems to improve and audit the timeliness of administration. Omitted medicine remains the highest category of medication errors reported to the NRLS2. Ensuring that patients receive their medication as prescribed and when they need it was highlighted as the responsibility of the nurse in charge in the Francis Report into Mid Staffordshire Hospitals3. Specialist Pharmacy Services (SPS) developed two “How to” guides to Monitoring the Incidence of Omitted Medicines and Designing and Implementing Interventions to reduce the incidence of omitted medicines4. In addition Tools to monitor the incidence of omitted medicines were also developed by SPS5.
Aim of this Resource This resource aims to collate examples of good practice that have been shared by organisations. The resources developed by organisations fit into the following categories:
Knowing the extent of the problem
Making sure that everyone knows which medicines are “critical medicines”
Improving access to medicines including access to ‘critical medicines’
Reducing the problems as they happen
Using financial and quality levers
Communication strategies Other
We are very grateful to the organisations that have shared their resources with us and ask that if you use them you acknowledge the author’s work.
1 Rapid Response Report NPSA/2010/RRR009: Reducing harm from omitted and delayed medicines in hospital, February 2010 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=66720 (accessed 28/10/2014)
2 Personal communication 2013 dataset, NHS England
3 Mid Staffordshire NHS Foundation Trust Public Inquiry, Chaired by Robert Francis QC, February 2013. http://www.midstaffspublicinquiry.com/report (accessed 28/10/2014)
4 "How to" Guides: Reducing the incidence of omitted medicines https://www.sps.nhs.uk/articles/how-to-guides-reducing-the-incidence-of-omitted-medicines-2/
(accessed 28/10/2014, link updated 10/08/2016) 5 Tools to monitor the incidence of omitted medicines https://www.sps.nhs.uk/articles/tools-to-monitor-the-incidence-of-omitted-medicines/ (accessed 28/10/2014, link updated 10/08/2016)
Medicines Use and Safety
Resources to Reduce the Incidence of Delayed and Omitted Medicines Vs1.1 – November 2014 (TR)
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Contents A. Knowing the extent of the problem ............................................................................................................................................................ 3
A.1 Audit methodologies ......................................................................................................................................................................... 3
A.2 Using electronic prescribing and medicines administration systems for audit purposes ......................................................................................... 4
B. Making sure that everyone knows which medicines are “critical medicines” ........................................................................................................... 5
B.1 Lists of “critical medicines” ................................................................................................................................................................. 5
B.2 Bulletins and ward posters of “critical medicines” ....................................................................................................................................... 6
C. Improving access to medicines including access to “critical medicines” ................................................................................................................ 7
C.1 Improved access to medicines – physical changes .................................................................................................................................... 7
C.2 Improved access to medicines – electronic “drug finders” ............................................................................................................................ 7
C.3 Improved access to medicines – decision making guides ............................................................................................................................. 8
C.4 Improved access to medicines – changes to pharmacy service ..................................................................................................................... 8
D. Reducing the problems as they happen ...................................................................................................................................................... 9
D1. Reducing the problems as they happen through electronic methods ............................................................................................................... 9
D2. Reducing the problems they happen through changes in practice .................................................................................................................. 9
E. Using financial and quality levers ............................................................................................................................................................ 11
E1. Use of CQUINs and Quality indicators ................................................................................................................................................. 11
F. Communication strategies .................................................................................................................................................................... 11
F1. Screen savers .............................................................................................................................................................................. 11
F2. Posters ....................................................................................................................................................................................... 12
F3. Education and training resources ........................................................................................................................................................ 12
F4. Using others to spread the message .................................................................................................................................................... 13
F5. Synergies with other campaigns ......................................................................................................................................................... 13
G. Other ............................................................................................................................................................................................. 13
G1.Care Homes ................................................................................................................................................................................. 13
©East & South East England Specialist Pharmacy Services
Medicines Use and Safety
Resources to Reduce the Incidence of Delayed and Omitted Medicines Vs1.1 – November 2014 (TR)
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A. Knowing the extent of the problem
A.1 Audit methodologies
Brief description More details Name of organisation Contact details
Specialist Pharmacy Services have developed some tools to monitor the incidence of omitted medicines. They include a data collection form and an Excel spreadsheet with embedded formula for some instantaneous results.
Link to resources
East and South East Specialist Pharmacy Services
Many trusts reported that they are collecting omitted doses data via the Medication Safety Thermometer
Link to Medication Safety Thermometer website
NHS England [email protected]
An example of an omitted doses audit collection form in an acute trust.
Link to document Southend University Hospital NHS Foundation Trust
An example of a weekly prescription check, used in a mental health trust, which amongst other things checks for omitted medicines. The data collection uses a system called Orbit.
Link to document Devon Partnership NHS Trust [email protected]
An example of an omitted doses audit collection form and guidance notes used in a community trust which also provides services to a prison.
Link to document
Link to document
Central London Community Healthcare NHS Trust (CLCH)
An example of an audit collection tool used in a community services organisation
Link to document Norfolk Community Health and Care NHS Trust
“Over the last two years monitoring the omitted and delayed doses has also become part of the focus of newly introduced medicines safety walkabouts”
Deputy Director of Pharmacy
Medicines Use and Safety
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A.2 Using electronic prescribing and medicines administration systems for audit purposes
Brief description More details Name of organisation Contact details
A number of trusts reported using electronic prescribing and administration systems in their organisations and that these give time real time audit data.
Link to e-prescribing toolkit
Link to presentations from SPS meeting on implementing EPMA in secondary care settings
East and South East Specialist Pharmacy Services
This trust specialises in inpatient and community mental health services
Lancashire Care NHS Foundation Trust [email protected]
This is an acute district general hospital
Bedford Hospital NHS Trust [email protected]
This trust includes two teaching hospitals, and integrated community services.
Guy's and St Thomas' NHS Foundation Trust
An integrated mental health, learning disability and community health services trust
Leicestershire Partnership NHS Trust [email protected]
“The key lesson from this work has been the importance of real time/on time data on a regular basis to engage and empower local champions to lead for improvement.”
Lead Pharmacist Medication Safety
Medicines Use and Safety
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B. Making sure that everyone knows which medicines are “critical medicines”
B.1 Lists of “critical medicines”
Brief description More details Name of organisation Contact details
UKMi developed a tool to support local implementation of the NPSA rapid response on omitted and delayed medicines which directed organisations to identify a list of critical medicines where timeliness of administration is crucial. This tool was not designed to replace individual local lists, but to assist organisations with the process.
Link to document
UKMi
Most trusts reported that they had locally agreed lists of critical medicines. These were often part of a larger policy or standard operating procedure and some examples are shared here:
Clinical Guideline - Continuity of Critical Medicines. (from an acute trust)
Link to document East Kent Hospitals University NHS Foundation Trust
SOP: Reducing Harm from Omitted and Delayed Medicines (from a community trust which also provides a service to a prison)
Link to document Central London Community Healthcare NHS Trust (CLCH)
The Critical Medication List (from an acute trust). This list includes local information about where the drugs may be located.
Link to document Southend University Hospital NHS Foundation Trust
Medicines that should not be omitted or delayed (from a teaching hospital). This document includes a form to record omitted or delayed doses
Link to document
Wirral University Teaching NHS Foundation Trust
Clinical Guideline - Omitted or delayed doses: Critical drugs list from an acute teaching hospital trust which included community health services.
Link to document Guy's and St Thomas' NHS Foundation Trust
Medicines Use and Safety
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B.2 Bulletins and ward posters of “critical medicines”
Brief description More details Name of organisation Contact details
A number of organisations reported that they have issued bulletins and posters to try to increase the awareness of staff as to what medicines are on the list of critical medicines.
Ward Poster from an acute trust Link to document Western Sussex Hospitals NHS Foundation Trust
This Bulletin/Poster from a mental health and community trust identifies the broad groups of critical medicines and outlines the responsibilities of the healthcare team
Link to document Central and North West London NHS Foundation Trust (CNWL)
This Bulletin from a mental health trust includes their list of critical medicines and shows staff how to record leave, late administration and self-administration.
Link to document Devon Partnership NHS Trust [email protected]
This list is from a community health, specialist mental health and learning disability services organisation
Link to document Southern Health NHS Foundation
This is an extract from a briefing document from a large acute and community trust which has a summary of the critical list of medicines.
Link to document South Tyneside NHS Foundation Trust [email protected]
“In our opinion all medicines are critical and no medicines should be omitted. ….We will be auditing all medicines that are omitted when we move to the NHS Safety Thermometer to know the full extent of any problems.”
Chief Pharmacist
Medicines Use and Safety
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C. Improving access to medicines including access to “critical medicines”
C.1 Improved access to medicines – physical changes
Brief description More details Name of organisation Contact details
Improved treatment room design, increased storage for medications and faster access (digital key pads for drug cupboards installed
University Hospitals Bristol NHS Foundation Trust
Developed satellite pharmacies in key areas and have a constant daily presence on these wards to enable efficient and timely supply of medication
University Hospitals of Morecambe Bay NHS Foundation Trust
Set up an emergency drugs room Basildon and Thurrock University Hospitals NHS Foundation Trust
C.2 Improved access to medicines – electronic “drug finders”
Brief description More details Name of organisation Contact details
Created an intranet page on access to medicines, which is on the quick links section of the intranet.
Link to document Imperial College Healthcare NHS Trust [email protected]
Developed a program called the ‘stock locator’. When the user types the drug they are searching for into the stock locator it informs the user where the drug is stocked.
The Pennine Acute Hospitals NHS Trust
The pharmacy website directs nursing staff to ‘Find a Drug’ which tells them which wards carry it.
Bedford Hospital NHS Trust [email protected]
“Changing the culture from ambivalence to one that values and maintains high standards in prescribing, administration and supply, at all levels within the system is the biggest challenge”
Medical Admissions Pharmacist
Medicines Use and Safety
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C.3 Improved access to medicines – decision making guides
Brief description More details Name of organisation Contact details
Decision making algorithm to guide nurses through what to do if a medicine is not available on the ward
Link to document Imperial College Healthcare NHS Trust [email protected]
These two algorithms guide staff through what to do in hours and out of hours
Link (in hours)
Link (out of hours)
Southend University Hospital NHS Foundation Trust
This algorithm guides nurses through what to do if the patient comes in with an MDS
Link to document East Sussex Healthcare NHS Trust [email protected]
This algorithm guides staff on what to do if a diabetic patient is admitted without their own insulin.
Link to document Bedford Hospital NHS Trust [email protected]
C.4 Improved access to medicines – changes to pharmacy service
Brief description More details Name of organisation Contact details
On call pharmacists can dispense remotely from home such that the drug is issued by the robot into a secure access area for the nurse to collect.
Western Sussex Hospitals NHS Foundation Trust
Use of an electronic prescription tracker which changes colour if the urgent item has not been processed in 15 minutes.
Guy's and St Thomas' NHS Foundation Trust
Pharmacy has a ‘red tray’ system in operation for critical medicines so that they are prioritised over all other work.
Southend University Hospital NHS Foundation Trust
A ‘critical drug request form’ has been developed and new processes within pharmacy are in place to prioritise dispensing of critical drugs.
University Hospitals Bristol NHS Foundation Trust
Medicines Use and Safety
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D. Reducing the problems as they happen
D1. Reducing the problems as they happen through electronic methods
Brief description More details Name of organisation Contact details
Electronic prescribing and administration system reminds staff who code doses as "drug not available" by alerting with a message: "now order from pharmacy".
Guy's and St Thomas' NHS Foundation Trust
Working with the provider of the electronic prescribing and medicines administration system to develop a way of incorporating drugs on the critical list so that they are flagged up as ‘time critical’ at the time of administration.
Bedford Hospital NHS Trust [email protected]
D2. Reducing the problems they happen through changes in practice
Brief description More details Name of organisation Contact details
The shift co-ordinator’s checklist now requires them to allocate someone to double-check the charts at the end of the shift.
Berkshire Healthcare NHS Foundation Trust
Formalisation of a nursing handover process which includes the communication of any omissions and delays in medicines administration, the reasons and any necessary follow-up. The reporting of missed doses is part of daily clinical indicators for wards to enable performance monitoring.
Lewisham & Greenwich NHS Trust [email protected]
A community services provider introduced a drug chart check at each handover, by the incoming senior nurse (before the previous shift leaves).
Virgin Care (Surrey Services) [email protected]
Medicines Use and Safety
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Addition of "Review drugs" onto the medical ward round check list in some areas, following the RCP/RCN Ward rounds in medicine - Principles for best practice guidance
Link to RCP/RCN guidance
Guy's and St Thomas' NHS Foundation Trust
Working towards the introduction of safety huddles which involve nursing handover at the bedside.
Medway NHS Foundation Trust [email protected]
Introduction of weekly medicines safety walkabouts to: increase staff awareness on medicines-related safety issues such as omitted doses, educate staff on the concept of medicines management, and obtain and act on information gathered that identifies areas for improvement in a timely manner.
Lewisham & Greenwich NHS Trust [email protected]
Use of a ward based technician to support drug rounds
Link to presentation Brighton and Sussex University Hospitals NHS Trust
Pilot project involving pharmacy technician supervising nursing drug administration rounds in order to promote safe medication practices and increase awareness of medicines management issues on a practical level in the ward setting
Lewisham & Greenwich NHS Trust [email protected]
The use of a decision aid for nurses at the point of omitting a drug
Link to document South Tyneside NHS Foundation Trust [email protected]
Implementation of ‘missed dose’ stickers which are available on all wards: nurses are asked to put one in the medical notes to highlight the missed dose to the rest of the multidisciplinary team. The sticker asks what steps were taken to avoid the occurrence.
Link to document Northwick Park Hospital [email protected]
“One strategy is unlikely to suit all areas, and we are collating various approaches that have led to improvement in the different divisions to develop a toolkit for reducing omissions”
Lead Pharmacist Medication Safety
Medicines Use and Safety
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E. Using financial and quality levers
E1. Use of CQUINs and Quality indicators
Brief description More details Name of organisation Contact details
A CQUIN supported the introduction of the Medication Safety Thermometer in 2013/14. This CQUIN was used in the Greater Manchester Area to support the development of the tool.
Link to previous CQUIN 2013/14
If you are interested in setting up a CQUIN in your locality and would like some information about the using the Medications Safety Thermometer contact [email protected]
Reducing the number of doses of critical medicines not administered to patients by nurses within a defined time period.
Link to document Royal Free London NHS Trust [email protected]
Development and implementation of a plan to put in place the actions described in NPSA RRR 009 and reduce harm from omitted and delayed medicines in Community Hospitals.
Link to document Norfolk Community Health and Care NHS Trust
F. Communication strategies
F1. Screen savers
Brief description More details Name of organisation Contact details
The use of screen savers across a trust has proved to be a useful communication strategy.
Link to document (Delayed doses)
Link to document
(Omitted doses)
Link to document
(Once only doses)
Guy's and St Thomas' NHS Foundation Trust
Medicines Use and Safety
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F2. Posters
Brief description More details Name of organisation Contact details
“Mind the Gap” poster Link to document Devon Partnership NHS Trust [email protected]
Imperial 3D rule Link to document Imperial College Healthcare NHS Trust [email protected]
On time, every time Link (prescribers)
Link (nurses)
Norfolk Community Health and Care NHS Trust
Link (prescribers)
Link (nurses)
Berkshire Healthcare NHS Foundation Trust
Critical medicines poster Link to document South West London and St George's Mental Health NHS Trust
Missed Doses Safety Cross Link to document Western Sussex Hospitals NHS Trust (for Sussex Partnership Trust)
Reducing delayed and omitted drugs on medicine administration rounds
Link to document Western Sussex Hospitals NHS Foundation Trust
Omissions poster Link to document Guy's and St Thomas' NHS Foundation Trust
F3. Education and training resources
Brief description More details Name of organisation Contact details
Slides on delayed and omitted medicines from a Medication Safety Day
Link to document Western Sussex Hospitals NHS Foundation Trust
Slides for a Harm Free Care training session Link to document St George’s Healthcare NHS Trust [email protected]
“We believe a multifactorial approach to communication is often needed for changing care/services” Consultant Pharmacist - Safe Medication Practice
Medicines Use and Safety
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F4. Using others to spread the message
Brief description More details Name of organisation Contact details
The introduction of Link Nurses Link to document University College London Hospitals NHS Foundation Trust,
1:1 training and support through Practice Development Nurses
Lewisham & Greenwich NHS Trust [email protected]
Use of "opinion leaders" - senior doctors, senior pharmacists, senior nurses
Guy's and St Thomas' NHS Foundation Trust
F5. Synergies with other campaigns
Brief description More details Name of organisation Contact details
Linking in with Parkinson’s UK “Get It On Time” campaign
Link to website
Parkinson’s UK
Linking in with Surviving Sepsis campaign Link to website
The Surviving Sepsis Campaign
G. Other
G1.Care Homes
Brief description More details Name of organisation Contact details
Reducing harm from omitted and delayed medicine doses in care homes
Link to document
North Somerset Clinical Commissioning Group
“In future when tackling a similar issue, we will start working with local champions rather than offering 'the solution' with a top-down approach”
Lead Pharmacist Medication Safety