The Royal United Hospital, Bath, admits approximately 550 patients with neck of femur fractures per year. The risks from returning to theatre for this patient group are often life-threatening. Post-operative wound ooze was noted to cause a significant rate of return to theatre, with increased lengths of stay and patient morbidity. A wound closure protocol was agreed by the consultant body. This information was disseminated by email and teaching sessions to all members of the multidisciplinary team, including surgeons, theatre staff and ortho-geriatricians. The plan-do-study-act model for improvement was used to reduce rates of returns to theatre for wound ooze. Interventions included cyclical teaching during each trainee rotation, updated inductions, posters, email reminders and scrub team involvement to open the protocol sutures unprompted. The primary outcome measure was returns to theatre for wound complications. Baseline data showed 4 returns to theatre over a two month period (4.40% of patients). Length of stay for each patient affected by wound ooze was also compared to the departmental mean. In the 6 month intervention period there was one return to theatre (0.36% of patients). The observed reduction saved the department an estimated £13,831 in length of stay alone. The standardisation of wound closure protocol, with continued reinforcement to all members of the multidisciplinary team, improves patient outcome in this group. Mobilising a group of clinicians across a variety of specialities, with one common goal, is highly effective for patients, improves multidisciplinary working and reduces cost.
"Early Aspirin" or a medium dose of aspirin 6 hours after Coronary Artery Bypass Graft (CABG) Surgery is strongly recommend by international guidelines (EACTS 2007/AHA 2011 guidelines, Level1a evidence) to protect venous graft patency. However, compliance with Early Aspirin prescription at our centre is poor due to long standing hospital cultural practices and lack of awareness. We completed a two-cycled retrospective audit of 53 (September 2015 Baseline), 65 (January 2016 First Cycle) and 58 (June 2016 Second Cycle) consecutive CABG patients. Interval interventions included educational presentations, educational leaflets/posters, pharmacy liaison and modifications to e-prescription order-sets. Medical, nursing and pharmacy staff were involved in the audit strategies. Early aspirin prescription improved from 23% to 48% to 55% while administration of Early Aspirin improved from 17% to 38% and finally to 48% by second improvement cycle. Significantly, the proportion of patients with omission of early aspirin despite a clear clinical indication, decreased by 50% over the audit period. Important practical considerations were the last dose of anti-platelets preoperatively and amount of of bleeding from mediastinal drains post operatively. A multidisciplinary team based approach led to a 139% improvement in prescription and 182% improvement in administration of "Early Aspirin" after CABG surgery.
Patient safety event reporting is an important component for fostering a culture of safety. Our tertiary care hospital utilizes a computerized patient safety event reporting system that has been historically underutilized by residents and faculty, despite encouragement of its use. The objective of this quality project was to increase patient safety event reporting within our Emergency Medicine residency program. Knowledge of event reporting was evaluated with a survey. Eighteen residents and five faculty participated in a formal educational session on event reporting followed by feedback every two months on events reported and actions taken. The educational session included description of which events to report and the logistics of accessing the reporting system. Participants received a survey after the educational intervention to assess resident familiarity and comfort with using the system. The total number of events reported was obtained before and after the educational session. After the educational session, residents reported being more confident in knowing what to report as a patient safety event, knowing how to report events, how to access the reporting tool, and how to enter a patient safety event. In the 14 months preceding the educational session, an average of 0.4 events were reported per month from the residency. In the nine months following the educational session, an average of 3.7 events were reported per month by the residency. In addition, the reported events resulted in meaningful actions taken by the hospital to improve patient safety, which were shared with the residents. Improvement efforts including an educational session, feedback to the residency of events reported, and communication of improvements resulting from reported events successfully increased the frequency of safety event reporting in an Emergency Medicine residency.
The Niagara Health System (NHS) in Ontario, Canada is comprised of three non-designated trauma center (NTC) hospitals which provide primary care to approximately 100 trauma patients annually. NTCs often lack standardized resources such as trauma surgeons, trauma-trained emergency room physicians, Advanced Trauma Life Support certified staff, trauma protocols, and other resources commonly found at designated trauma centers. Studies indicate that these differences contribute to poorer outcomes for trauma patients treated at community hospitals in Ontario, including the NTC hospitals of the NHS. In other settings healthcare checklists and bundles have proven effective in streamlining processes to ensure effective, efficient and timely patient care. Quality Improvement (QI) tools and methods were used to design, implement, and evaluate a trauma care bundle at one of the NHS's community hospitals. We assessed outcome and process measures through a chart audit of all trauma care patients in the NHS from July 2015 - November 2015. A Safety Attitudes Questionnaire (SAQ) was administered to health system staff who were involved in the pilot to assess balancing measures. Between July-November 2015, 39 patients were treated at the St. Catharines Hospital that were identified as either Canadian Triage and Acuity Scale (CTAS) I or CTAS II trauma patients. Of those 39 major trauma patients, 15 received care using the trauma care bundle, representing a 38% uptake. Patients who received care with the trauma bundle had an average Emergency Department (ED) length of stay (LOS) of 1.7 hours, compared with those patients in whom the bundle was not used, whose average ED LOS was 3.4 hours. The SAQ administered to ED physicians who used the bundle (n=10) highlighted the impact on ED patient safety. These early findings suggest that the bundle provides a substantial improvement to the current trauma care process within the Niagara Health System.
This project was started after an incident of bisphosphonate-induced hypocalcaemia in September 2015. As part of management of lytic bone lesions in patients with multiple myeloma were given either Zoledronic Acid or Pamidronate Disodium at our Haematology Day Unit. According to the British National Formulary (BNF), it is necessary to correct disturbances of calcium metabolism (e.g. vitamin D deficiency, hypocalcaemia) and consider dental check-ups before starting bisphosphonate infusion due to the risk of osteonecrosis of the jaw. There was no formal checklist in place for all patients prior to starting bisphosphonate infusion. The aim of this quality improvement project was (1) to avoid preventable bisphosphonate induced adverse effects, (2) to improve safety of bisphosphonate prescribing and administration and (3) to increase patient's awareness of needing regular dental checks. Interventions were modified over multiple Plan-Do-Study-Act (PDSA) improvement cycles to improve bisphosphonate infusion monitoring and patient safety.There was an overall improvement in ensuring safety checks were done prior to administration of bisphosphonate infusion compared to baseline measurements. At baseline, 36% (n=9) of patients had a dental check within the last 6 months; after PDSA cycle 3, there was an improvement of up to 69% (n=11). All patients had renal function and bone profile checked prior to infusion from throughout the study. It was all recorded in the blood results section of the checklist with no missing data. We found that 32% (n=8) of patients had never had 25-OHD at baseline. After PDSA cycle 3, all patients had 25-OHD checked at some point.
Children with cancer and fever are at high risk for sepsis related death. Rapid antibiotic delivery (< 60 minutes) has been shown to reduce mortality. We compared patient outcomes and describe interventions from three separate quality improvement (QI) projects conducted in three United States (US) tertiary care pediatric emergency departments (EDs) with the shared aim to reduce time to antibiotic (TTA) to < 60 minutes in febrile pediatric oncology patients (Temperature > 38.0 C). A secondary objective was to identify interventions amenable to translation to other centers. We conducted a post project analysis of prospectively collected observational data from children < 18 years visiting these EDs during independently conducted QI projects. Comparisons were made pre to post intervention periods within each institution. All interventions were derived independently using QI methods by each institution. Successful as well as unsuccessful interventions were described and common interventions adopted by all sites identified. A total of 1032 ED patient visits were identified from the three projects. Improvement in median TTA delivery (min) pre to post intervention(s) was 118.5–57.0 at site 1, 163.0–97.5 at site 2, and 188.0–111.5 at site 3 (p<.001 all sites). The eight common interventions were 1) Triage application of topical anesthetic 2) Rapid room placement & triage 3) Resuscitation room placement of ill appearing children 4) Close proximity to central line equipment 5) Antibiotic administration before laboratory analyses 6) Consensus clinical practice guideline establishment 7) Family pre-ED education for fever and 8) Staff project updates. This core set of eight low cost, high yield QI interventions were developed independently by the three ED's which led to substantial reduction in time to antibiotic delivery in children with cancer presenting with fever. These interventions may inform future QI initiatives in other settings caring for febrile pediatric oncology patients.
Patients who are high risk high cost (HRHC), those with severe or multiple medical issues, and the chronically ill elderly are major drivers of rising health care costs.1 The HRHC patients with complex health conditions and functional limitations may likely go to emergency rooms and hospitals, need more supportive services, and use long-term care facilities.2 As a result, these patient populations are vulnerable to fragmented care and "falling through the cracks".2 A large county health and hospital system in California, USA introduced evidence-based interventions in accordance with the Triple AIM3 focused on patient-centered health care, prevention, health maintenance, and safe transitions across the care continuum. The pilot program embedded a Transitional Care Manager (TCM) within an outpatient Family Medicine clinic to proactively assist HRHC patients with outreach assistance, problem-solving and facilitating smooth transitions of care. This initiative is supported by a collaborative team that included physicians, nurses, specialists, health educator, and pharmacist. The initial 50 patients showed a decrease in Emergency Department (ED) encounters (pre-vs post intervention: 33 vs 17) and hospital admissions (pre-vs post intervention: 32 vs 11), improved patient outcomes, and cost saving. As an example, one patient had 1 ED visit and 5 hospital admission with total charges of $217,355.75 in the 6 months' pre-intervention with no recurrence of ED or hospital admissions in the 6 months of TCM enrollment. The preliminary findings showed improvement of patient-centered outcomes, quality of care, and resource utilization however more data is required.
The assessment of post-operative patients is vital to identify early complications and ensure patient safety. Good clinical record keeping is essential for effective continuity of care and patient safety in the post-operative period. A group of foundation year 2 (FY2) doctors noted a disparity in levels of confidence and ability in performing this assessment. The aim of the project was to improve documentation and understanding of day one lower limb arthroplasty reviews by FY2 doctors. The Plan-Do-Study-Act model for continuous improvement was adopted from September 2015 to July 2016. A composite score comprising the twelve most important review parameters for documentation was used to score the quality of documentation on an ongoing basis. An electronic survey was completed by every FY2 rotating through the department. Interventions included registrar-led teaching sessions and an integrated review form placed in the medical notes. Further iterations of the proforma and further interventions were coordinated with the ward clerks, sisters, physiotherapists and senior clinicians. The baseline mean composite score was 6.3/12. Following implementation of a standardised proforma this score improved to 10.5 in those who had used the proforma, but 5.7 in those who hadn't. Electronic survey responses showed the proforma and teaching were effective in improving knowledge and understanding of post-operative reviews. The use of an integrated proforma in the medical notes and teaching it's use at induction, improves the documentation and understanding of day one post-operative reviews. Coordinating ward-based change across a cohort of FY2s, with involvement from the multidisciplinary team and management, affects sustained improvements in patient reviews.
Hand Hygiene is the cheapest and simplest way to prevent the spread of infection, however international compliance is below than 40% (WHO, 2009). In the experience of Al Wakra Hospital, the improvement in hand hygiene compliance highlighted not just interventions towards training and education but also behavioral motivation and physical allocations of hand hygiene appliances and equipment. Through motivating the behavioral, emotional, physical and intellectual dimensions of the different healthcare worker professions, hand hygiene compliance has increased from 60.78% in 2011 to 94.14% by the end of December 2015. It took 25 months of continuous and collaborative work with different healthcare workers to reach the 90% hand hygiene target. "Together, we have reached our goals and together we fight against infections! Because we always strive for excellence in everything we do - that is our vision here in Al Wakra Hospital."
From 7/2014 through 6/2015, 10 emergency department (ED) medication dosing errors were reported through the electronic incident reporting system of an urban academic medical center. Analysis of these medication errors identified inaccurate estimated weight on patients as the root cause. The goal of this project was to reduce weight-based dosing medication errors due to inaccurate estimated weights on patients presenting to the ED. Chart review revealed that 13.8% of estimated weights documented on admitted ED patients varied more than 10% from subsequent actual admission weights recorded. A random sample of 100 charts containing estimated weights revealed 2 previously unreported significant medication dosage errors (.02 significant error rate). Key improvements included removing barriers to weighing ED patients, storytelling to engage staff and change culture, and removal of the estimated weight documentation field from the ED electronic health record (EHR) forms. With these improvements estimated weights on ED patients, and the resulting medication errors, were eliminated.
Care home residents are 3 times more likely to fall than their community dwelling peers and 10 times more likely to sustain a significant injury as a result. 2 A project commenced at a care home in Aberdeen with the aim of reducing the number of falls by 20% by 30st April 2016 using the model for improvement. Qualitative data was gathered to establish staff belief about falls and their level of knowledge& understanding about falls risks and how to manage these. This informed the training which was delivered and iterative testing commenced with the introduction of the Lanarkshire Falls Risk/Intervention tool - where the multifactorial nature of a resident's falls risks are explored and specific actions to manage these are identified and implemented. Failure to meet PDSA predictions about sharing risk reducing actions with staff and length of time to complete the tool prompted a focus on communication and the processes whereby the tool is completed. "Teach back" was employed to highlight communication difficulties and ultimately the introduction of Huddles out improved the flow of information about residents and informed the Falls Risk/Intervention tool. 5 PDSAs were completed and within them multiple tests of change. The improvement shift came following a root cause analysis of the nature & cause of one resident's falls and applying the tool & communication processes. The average falls rate fell from 49 per 1000 occupied bed days to 23.6 and was sustained because of the attention to the importance of communication. The aim was achieved with a 36.6% reduction in Falls rate. Care home residents are 3 times more likely to fall than their community dwelling peers and 10 times more likely to sustain a significant injury as a result. 2 A project commenced at a care home in Aberdeen with the aim of reducing the number of falls by 20% by 30th April 2016 using the model for improvement. Qualitative data was gathered to establish staff belief about falls and their level of knowledge& understanding about falls risks and how to manage these. This informed the training which was delivered and iterative testing commenced with the introduction of the Lanarkshire Falls Risk/Intervention tool - where the multifactorial nature of a resident's falls risks are explored and specific actions to manage these are identified and implemented. Failure to meet PDSA predictions about sharing risk reducing actions with staff and length of time to complete the tool prompted a focus on communication and the processes whereby the tool is completed. "Teach back" was employed to highlight communication difficulties and the introduction of Huddles improved the flow of information. 5 PDSAs were completed and within them multiple tests of change. The improvement shift came following a root cause analysis of the nature & cause of one resident's falls and applying the tool & communication processes. The average falls rate fell from 49 per 1000 occupied bed days to 23.6 and was sustained because of the attention to the importance of communication. The aim was achieved with a 36.6% reduction in Falls rate.
Acute sore throat is a common presentation in primary care settings. We aimed to improve our compliance with national antibiotic guidelines for sore throat symptoms to 90% in 3 months' time period. The national guidelines are based on Centor criteria. A retrospective audit of 102 patient records with sore throat symptoms presenting between 1 January to 30 December 2015 showed that over 50% were given antibiotics. Those who were prescribed antibiotics, 27% did not meet NICE criteria and 85% of patients were given immediate antibiotic prescription. Centor criteria was documented in just 2% of cases. Compliance with correct antibiotic course length was 15%. Antibiotic choice and dose was correct in 94% and 92% of cases respectively. Antibiotic frequency was correctly prescribed in 100% of patients. We introduced interventions that included oral and poster presentations to multidisciplinary team, dissemination of guidelines through internal e-mail and systemic changes to GP electronic patient record system EMIS. This involved creating an automated sore throat template and information page. On re-auditing of 71 patients, after two PDSA cycles, compliance with NICE criteria was 87% with a significant reduction in immediate prescribing (66%). Centor criteria documentation was 42%. Correct antibiotic course length was prescribed in over 30% of cases. Other antibiotic regimen parameters (choice, dose and frequency) were correct in 100% of cases. The initial results demonstrated that significant changes were needed. In particular, reducing the amount of antibiotics prescribed by increasing compliance with NICE criteria and ensuring all parameters of antibiotic prescription were correct. We showed that significant sustainable improvement is achievable through carefully devised automated systemic changes that provides critical information in readily accessible format, and does not solely rely on prescribers' knowledge and initiative. The outcome of these interventions are a decrease in immediate antibiotic prescription, significant increase in Centor criteria documentation and an increase in compliance with the correct course length of antibiotics. All these measures would contribute to reduction in antimicrobial resistance and improvement in patient care in the community. Future work must focus on improving compliance with correct antibiotic course length.
Dartmouth-Hitchcock Medical Center is a rural, academic medical center in the northeastern United States; its General Internal Medicine (GIM) division performs about 900 low and intermediate surgical risk preoperative evaluations annually. Routine preoperative testing in these evaluations is widely considered a low-value service. Our baseline data sample showed unnecessary testing rates of approximately 36%. A multi-disciplinary team used a micro-systems approach to analyze the existing process and formulate a rapid cycle improvement strategy. Our improvement efforts focused on implementation of a Nurse Practitioner and Physician Assistant (Associate Provider) clinic to incorporate standardized protocols for preoperative assessment. Plan-Do-Study-Act (PDSA) cycles included creation of a dedicated Associate Provider run preoperative clinic, modifying and operationalizing a scheduling scheme, and creating and implementing Electronic Health Record (EHR) tools. We used Statistical Process Control (SPC) methods to analyze time ordered data for the usual care process and to compare performance with the novel preoperative clinic. The Associate Provider preoperative clinic showed unnecessary testing rates of 4% compared with 23% in the usual care cohort (p<.001) within 3 months of implementation. When testing rates across the entire division were analyzed, there was no significant change. In our GIM division this preoperative clinic was effectively staffed with Associate Providers. Dedicated leadership support, incorporating input from a diverse improvement team, and balancing innovation with other clinical needs are important elements for success. We hypothesize that protecting clinical time to focus on preoperative care, monitoring and modifying scheduling processes, and improving support for electronic health record tool implementation would have yielded further performance improvements. Our experience provides valuable learning for other primary care practices with similar challenges. Identifying appropriate patients for inclusion in these clinic visits while optimizing primary care provider collaboration are important future challenges.
Colonoscopy is a key investigation used to exclude large bowel pathologies including surveillance for CRC (Colorectal cancer) Poor bowel preparation (bowel prep) is one of the most important factors affecting its diagnostic yield. Different formulations of bowel prep are currently in use depending upon patient tolerance, indication & co-morbidities. In University Hospital Llandough we retrospectively reviewed the outcome of colonoscopies performed over period of 3 months, in relation to the type and outcome of bowel preparations used. We implemented a change of patient instruction and pre-assessment of bowel preparation prescribed. We repeated the same measurements over 3 different cycles on 3 different occasions and compared the outcome. We noticed that quality of bowel preparation noticeably improved from 80% to almost 93% if patients were given appropriate advice in a written format, prior to procedure. In addition to improvement in the quality of assessment & reducing the number of repeat procedures, by changing the bowel preparation product and postage methods we estimated savings of almost £150,000 for the trust in a year.
Dementia is a common condition, and people with dementia occupy around 25% of hospital beds. Commissioning for Quality and Innovation (CQUIN) is an NHS payment framework that links part of English healthcare providers' income to quality improvement. The dementia CQUIN goals are designed to encourage the recognition of dementia in hospital. The Royal Surrey County Hospital, Guildford, introduced new procedures to meet the dementia CQUIN targets. Adherence to the changes was a problem. This project aimed to improve hospital's implementation strategy. At baseline, completion rates for dementia CQUIN assessments were just 27%. Interventions were informed by semi-structured interviews with junior doctors and dementia leads in neighbouring trusts. Progress was measured by regular audits and interventions were made over several months. Changes suggested by junior doctors and nurses proved very effective, and involving the multidisciplinary team produced the most significant improvement. Gradual progress was made until we achieved and maintained 90% completion for dementia assessments. In conclusion, we made changes to working practices to achieve the CQUIN targets and promoted quality care for older adults. Our experience highlighted the importance of involving multidisciplinary frontline staff in the design of service changes.
Iron deficiency and anaemia are common in pregnancy. Audit data from our tertiary obstetrics unit demonstrated 22% of maternity patients experiencing a postpartum haemorrhage received a transfusion; a third of whom were anaemic on admission intrapartum. Australian Patient Blood Management (PBM) Module 5 Obstetrics guidelines focuses on maximising red cell mass at the time of delivery and reducing the reliance on transfusion as a salvage therapy to treat blood loss. A clinical practice improvement partnership began in February 2015 and completed in April 2016; which aimed to implement systems to improve antenatal identification and management of iron deficiency, and improve postpartum anaemia management. In order to develop change strategies, reasons for poor detection and correction of iron deficiency in the antenatal period were identified following a quality improvement methodology. Education was delivered to maternity healthcare providers. Standardised algorithms and an oral iron prescription handout were developed and piloted. Follow-up audit, staff and patient feedback, and other hospital data were collected to measure outcomes. The rate of anaemia on admission intrapartum fell from 12.2% in 2013 to 3.6% in 2016 following the introduction of unselective ferritin screening and other antenatal interventions. Sixty to 70% of maternity patients screened each month had iron deficiency. The algorithms aided staff to become confident in blood test interpretation and management of iron deficiency and anaemia. Patients found the oral iron prescription handout helpful. Additionally, single unit transfusions significantly increased from 35.4% to 50% (p=0.037) over the project timeframe. This project demonstrated the potential to improve patient blood management in obstetrics, reduce anaemia and transfusions by active antenatal interventions.
Between January and October 2014, Great Ormond Street Hospital Paediatric Intensive Care Unit (PICU) was spending an average £23,392 on blood tests per month. Blood tests should be requested based on previous results and the patient's clinical condition, medication and nutritional status. However, more blood tests were being ordered than clinically indicated: an audit in October 2014 showed liver function tests (LFTs) were requested daily on most patients, even with previous normal results. A driver diagram identified three primary drivers for blood test requesting: decision-making, situational awareness and computer-based ordering. Decision-making for routine blood tests was the responsibility of the bedside nurses on each night shift. The communication between the nurses and doctors was an identified secondary driver. The project's primary aim was to reduce unnecessary LFTs requests on PICU over 6 months by implementing a blood test request form, a table of common investigations to facilitate and document discussion between the nursing and medical teams. The secondary aims were to reduce other unnecessary blood test requests, including full blood counts (FBC), coagulation screens and CRP. This project was conducted in three phases: construction, testing and implementation of the blood test form. PDSA cycles were used within each phase. Two PICU nurse champions were engaged to provide bedside support, education and feedback. In the 8-month period following implementation, there was a significant sustained reduction in LFTs requests. A similar pattern of sustained reduction also occurred for FBC, coagulation screens and CRP requests. This sustained reduction in blood tests requested equated to a saving in excess of £36,000. This project was successful: the reduction in the number of inappropriate blood tests had clear financial benefit for PICU and reduced blood loss for patients. Early engagement and support from key stakeholders avoided conflict, guaranteed data sharing and aided engagement of bedside nurses.
There is mounting evidence that communication and hand-off failures are a root cause of two-thirds of sentinel events in hospitals. Several studies have shown that non-standardized hand-offs have yielded poor patient outcomes and adverse events. At Stony Brook University Hospital, there were numerous reported adverse events related to poor hand-off during the transfer of patient responsibility from one resident caregiver to the next. A resident-conducted root cause analysis identified lack of a standardized hand-off process and formal training on safe and efficient hand-off among caregivers as key contributing factors. This quality improvement project used the PDSA methodology to test the use of a standardized method, the IPASS mnemonic, and compare it to our conventional hand-off method in our internal medicine residency program. The main goals of this study were to test the feasibility and effectiveness of a standardized I- PASS hand-off and to create a robust sustainability model that includes 1) integration of I-PASS handoff in the Electronic Medical Record (EMR), 2) direct observation of the hand-off process by faculty and senior residents, and 3) surveillance and reporting of hand-off compliance scores. Compared to hand-off with a conventional method, the use of the I-PASS method resulted in significantly fewer reported adverse events (χ2=4.8, df=1, p=0.04). I-PASS was successfully integrated into our EMR system and residents were mandated to use this as the sole method of hand-off. An EMR audit conducted six months after implementation revealed poor compliance, which ultimately led to the creation of a sustainability model that improved overall compliance from 60% to 100%.
Patient experience is central to the delivery of excellent healthcare. As such it is enshrined within the 2015 NHS outcomes framework, a set of indicators against which quality in healthcare is measured. A variety of tools are available to quantify patient experience across clinical settings. When combined with a framework for continued data collection and suitable mechanisms for analysis, feedback, and intervention, these tools allow improvements in patient care and clinical services to be realised. In response to an increasing number of patient complaints and friends and family scores below the trust average within our orthopaedic department we instituted an improvement programme in March 2015. The programme was based around the Picker Patient Experience 15 questionnaire and aimed to improve friends and family test scores, reduce complaints and improve patient experience scores over an 18-month period. An improvement model including baseline measurement and 2 improvement cycles over an 18-month period was used. Initial benchmarks for practice were created by referencing national data allowing problem areas of care to be identified and interventions to address these developed. This process identified areas for improvement including improving staff awareness and engagement with patient experience, improving staff and patient communication and ensuring patients were aware and involved in plans for their own care. Actions to address these issues resulted in a 38% decrease in patient complaints, a >10% increase in patient experience, and improvements in patient satisfaction and friends and family scores.
Medicines reconciliation is integral to patient safety, symptom control and reducing patient anxiety. During a 3-month period on the respiratory ward at St. Peter's Hospital, 54% of drug charts were not reconciled with pre-admission medicines at the point of discharge for admissions up to 17 days. Only 18% were reconciled within 24 hours of admission. 50% of drug charts were missing 0-2 pre-admission medicines and 50% were missing 3-5 pre-admission medicines. The most common medicines that were not reconciled included topical applications which included eye, ear, nasal and skin applications (14%); vitamins i.e. vitamin B12 and thiamine, analgesia, PRN inhalers (11% individually); antidepressants and lipid regulators (6% individually); amongst a range of other medications including antiplatelets, calcium channel blockers, ACE inhibitors and diuretics. Two interventions were carried out to improve the rate of medicines reconciliation onto hospital drug charts with pre-admission medicines. These were: 1) a green sticker placed in the medical notes by the pharmacist when drug charts were incomplete, which required a date and signature from the doctor when the drug chart had been reconciled 2) the placing of the loose medicines reconciliation record (a list of pre-admission medicines retrieved from a reliable source usually by the pharmacist) to the front of the drug chart. These measures were designed to alert the doctors that the drug chart was incomplete. After 2 PDSA cycles, the results showed positive outcomes. In 75% of the cases where the interventions were used, medicines reconciliation was complete at the point of discharge with 34% of drug charts reconciled within 24 hours of admission. Of the 25% of drug charts that were not reconciled despite the use of the interventions, 100% of them were missing 0-2 medicines however 0% were missing 3-5 medicines. This highlights that the interventions were effective in improving the rates of medicines reconciliation.
