Hospital Code Name: Jason

1. Innovation Poster Session HRT1210 – Patient Safety Sydney 14-15 June 2012 Improving Prescribing Medication Errors – Once Weekly Medication Re-charting in the Spinal Ward Presenter: Dana Mouwad Hospital Code Name: Jason

2. KEY PROBLEM OR MEASUREMENT AREA During long hospital stays spinal patients are prescribed up to 30 medications which requires regular medication re-charting (prescribing) Medications were being accidently omitted or transcribed incorrectly during re-charting process due to: interruptions from other health care professionals or the spinal unit doctor being unfamiliar with ICU patient transfers Incident reports identified prescribing and administration errors were the most frequently occurring medication error in the spinal ward A SAC 1 incident prescribing error related to a serious adverse event requiring RCA investigation (May 2008) A subsequent SAC 2 incident prescribing error required a detailed incident review (March 2009)

3. AIM OF THIS INNOVATION To minimise medication prescribing errors and improve medication safety by introducing once- weekly medication re-charting in the spinal ward at the hospital Time allocation for doctors to re-chart (prescribe) medication without interruption Doctors to check drug interactions during re-charting Review of medication charts with ward pharmacist after re-charting Education for doctors and nurses to reduce prescribing & administration errors

4. BASELINE DATA Pre Intervention - Jan 2008 to May 2008 Phase 1 – June 2008 to Feb 2009 Phase 2 – March 2009 –to June 2009 Phase 3- June 2009 to March 2010

5. KEY CHANGES IMPLEMENTED Phase 1 - weekly multidisciplinary (MDT) meeting to check all medication charts (doctors & pharmacist) following sac 1 prescribing incident May 2008 Despite this intervention a subsequent sac 2 prescribing error occurred March 2009. Identified that the weekly meetings were checking charts that were often close to expiry therefore reducing the effectiveness of surveillance Additional Intervention implemented for all medications to be re-charted at the same time by the same doctor, & all medications reviewed by the MDT meeting within 24 hours Phase 2 – was to reduce medication re-charting by doctors outside of spinal team & to support Junior doctor allocated to re-charting by having a systematic process involving senior registrars, staff specialists & the ward pharmacist

6. KEY CHANGES IMPLEMENTED Educational sessions “minimising medication error” for doctors & nurses were conducted at the weekly MDT meeting, & ward orientation Meeting was used as an opportunity for training & promoting good prescribing practice Phase 2 evaluated by medication chart audits conducted by the pharmacist using the National Inpatient Medication Chart (NIMC) audit tool Doctors & Nurses were surveyed Phase 3 – Improve audit tools, longitudinally follow outcomes & adapt intervention Phase 2 results led to intervention change; junior doctor request for protected time to prescribe / re-chart medications Common errors displayed in the charting room Incident results of 3 phases compared

7. OUTCOMES SO FAR Comparisons of incident reporting across the 3 phases Pre Intervention & Phase 1

8. OUTCOMES SO FAR Comparisons of incident reporting across 3 phases Phase 2

9. OUTCOMES SO FAR Comparisons of incident reporting across 3 phases Phase 3

10. LESSONS LEARNT Sustaining change…….. Once weekly medication re-charting & MDT medication round is time-consuming however some doctors felt more organised with allocated time to complete task without interruptions Difficult to maintain enthusiasm across all senior medical staff due to time required for the MDT weekly meeting Appears to improve prescribing within spinal medicine setting Resource intensive & relies on constant reinforcement of clinician behaviour across all disciplines Units without high volume of medications may not be prepared to invest in this initiative Needs to be clinician led through multiple disciplines – control of this issue can be lost due to staff turnover, vacancies, which can impact on continued behaviour change