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The Scottish Patient Safety Programme


The Scottish Patient Safety Programme NHS Fife Medicines Management Workstream Medicines Management in Fife Warfarin Safety Insulin Safety Medicines ... – PowerPoint PPT presentation

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Title: The Scottish Patient Safety Programme

The Scottish Patient Safety Programme
NHS Fife Medicines Management Workstream
NHS Fife Medicines Management Team
Donald Coxon Chief Pharmacist Team
Leader Sandy Kopyto Anticoagulation Lead Bruce
Wilkie Medicines Reconciliation Lead Paul
Smith Workstream Coordinator/Facilitator Valuab
le support is provided by a variety of medical
staff, nursing staff, pharmacists and others
including - Pauline Cumming (NHS Fife Risk
Manager), Dr Laura Clark (Acute Consultant
Physician), Dr Lynn Miller (Consultant
Cardiologist), Dr Krishnan Swaminathan (Diabetes
Consultant), Dr Vera Cvoro (Care of the Elderly
Consultant), Euan Reid (Senior Clinical
Pharmacist), Sharon Robertson (Diabetes
Specialist Nurse), Tessa Kidd (Diabetes
Specialist Nurse), Caroline Craig (Diabetes
Specialist Nurse), Rhona Wallace (Practice
Development Facilitator), Lorna Bellingham
(Senior Charge Nurse), Lorraine McComiskie
(Preassessment Nurse), David Binyon (Development
Pharmacist), Cath Stewart (Nurse Practitioner),
Hazel York (Diabetes Specialist Nurse), Julie
ONeill (CHP Risk Manager), Alan Timmins
(Principal Pharmacist), Dr Stella Clark (Medical
Director PCD), Jenny Stooke (Care Home Nurse)
Medicines Management in Fife
  • Warfarin Safety
  • Insulin Safety
  • Medicines Reconciliation

Improving Warfarin Safety
  • In 2008, Multi disciplinary team carried out a
    Failure Modes Effects Analysis (FMEA)
  • Developed action plan to address highest risks
    identified around patient education,
    communication with Primary Care and Prescribing.
  • Key improvements included enhancements to patient
    education/counselling sheet, discharge process
    incl. mandatory INR follow up appointment with GP
    and prescribing protocols with more varied
    loading regimes
  • Process supported by regular review of action
    plan implementation and monthly case note reviews
    and audit of discharges in Primary Care by
  • The case note review process has identified links
    with high INR and co-prescribing of antibiotics
    to be highlighted in forthcoming protocol
  • Measurement is constantly being refined now
    measure number of patients with INR over 6 per
    hospital, per month rather than overall
    percentage of INRs over 6 as many patients have
    multiple draws

(No Transcript)
What tests of change did we carry out
  • Warfarin Counselling sheet first on CCU in
    Victoria Hospital, then to Ward 15 then to Queen
    Margaret Hospital
  • Warfarin Discharge sheet
  • Prescribing Protocols part of wider review of
    Operational Division drug chart still being
    tested in one hospital now in 4th draft
  • Case note review trigger tool form now in 4th
  • Document control stamp on everything

Number of patient with INR over 6 at Victoria
Hospital Kirkcaldy
This measure was introduced as it became apparent
that the previous measure relating to percentage
of INRs over 6 per month was failing to show
improvement as it contained multiple draws for
several patients
Number of patient with INR over 6 at Queen
Margaret Hospital Dunfermline
Differences were noted between the 2 main
hospitals. These have been linked to the variance
in Pharmacy support and compliance with patient
Case Note Reviews Antibiotic interactions with
Monthly case note reviews for a sample of 20
patients/month admitted with INR over 6 continue
to identify antibiotic triggers with a high
percentage of patients. We are now starting to
identify where these have been prescribed. The
issue will be highlighted in the forthcoming
anticoagulation protocol
Warfarin Safety reducing the FMEA score
The team meets regularly to review progress and
identify new risks. We have been able to reduce
the FMEA RPN score from 1523 to 864. We are
however still finding pockets of non compliance
and areas we missed!
Improving Insulin Safety
  • In September 2009, multi disciplinary team incl.
    care home sector carried out a FMEA. The group
    has subsequently met 6 times and communication
    has been particularly highlighted to ensure that
    everyone who needs to know or has an interest is
    involved. The Diabetes MCN is regularly updated
    and hopefully patient involvement by 2011
  • The FMEA document is now in version 2.2 and the
    action plan in version 6. The highest risks
    identified were around prescribing information,
    communication and referral pathway information as
    well as staff education
  • Key improvements included enhancements to - IV
    and subcutaneous insulin prescribing charts,
    hypoglycaemia and hyperkalaemia protocols and a
    Fife-wide review of the Diabetes Handbook
  • Process supported by regular review of action
    plan implementation and audits e.g. on
    prescribing quality
  • Identifying suitable measures has been difficult
    have looked at insulin prescribing audit to
    identify error base rate and also at issue of
    hypo antidote products from Pharmacy to indicate
    better management and control.

What tests of change/improvements have we carried
  • IV insulin prescribing chart now underway
  • Subcutaneous insulin chart not started yet
  • Review of Fife Diabetes Handbook underway

Improving Insulin Safety - Measurement
We have tried to develop a measure to identify a
reduction in our hypoglycaemia rate by asking
pharmacy to provide data on the issue of glucose
gel and glucose 50 injection products as a
percentage of all glucose products but hasnt
really been successfulnow looking at a
prescribing error rate based on PSF insulin
Other FMEAs?
  • The process has worked very well for us in
    looking at high risk medications.
  • 2 more are planned long term
  • Chemotherapy
  • Opiates

Anything else?
  • Communication making sure everyone knows who
    needs to know
  • Strict document control
  • Project management who is going to do things,
    by when, how are they going to do them, what will
    be the impact on other services, who needs to
    know, information management, costs e.g. printing

Implementing Medicines Reconciliation
  • Our biggest challenge
  • Only implemented successfully in one ward, but
    analysis of discharge letters from this area have
    shown them to be of high quality due to
    reconciliation that has taken place on admission.
  • Acute admissions units still not compliant
    despite continuous efforts to identify a process
    that works
  • Now are routinely getting ECS printouts which are
    being added to patients notes during clerk in

Medicines Reconciliation why hasnt it worked?
  • We have asked this question many times
  • Not enough time to do properly during admissions
    process, lack of understanding/clarity of
    definition, lack of standardised admissions
    processes and documentation, doctors rotate
    frequently, ECS issues (consent, printouts),
    pharmacy support not always available, no patient
    or relative education, not seen as critical, lack
    of an easy IT solution, difficult to find
    evidence e.g. incident data to prove level of
    potential harm, no one-size-fits-all solution

Medicines Reconciliation what is going well
  • We have a thoroughly tested medicines
    reconciliation form that works and captures all
    essential information.
  • Ward clerks are now printing off ECS for all
    patients in medical acute admissions units where
    they are not accompanied by a GP letter
  • We are concentrating our efforts on utilising the
    ECS print out as the basis for medicines
    reconciliation but it is not designed for that
    purpose, not enough doctors are signed on and we
    havent managed to achieve sufficient awareness
    or acknowledgement that this is a critical
    admissions component

Medicines Reconciliation measurement
Compliance is very high in the one area to which
we have introduced this process. We have recently
held a review with Preassessment, nursing and
Practice Development staff on the ward. The
process is popular with doctors and has been seen
to enhance quality of discharge letters. Case
Note reviews and audits are planned to verify this
NHS Fife Medicines Management workstream What
is our plan?
  • Next steps in Medicines Management
  • Develop the medicines reconciliation process
    using ECS printouts if possible and identifying a
    process which doctors, nurses and pharmacists can
    live with and which makes a difference to
    patients! (We now have a new Acute Admissions
    Consultant who is keen to drive this and recruit
    FY1/2 doctors to assist
  • Continue testing and spreading of insulin IV and
    Subcutaneous prescribing guidance and complete
    the review of the Diabetes handbook by December
  • Tidy up some loose ends with the warfarin safety
    work complete the NHS Fife protocol, provide
    education for community hospitals, and so on