Medicines management safety scheme rolled out across south west England

By Ailsa Colquhoun

Award-winning work by South Devon Healthcare NHS Foundation Trust has led NHS South West to roll out a medicines safety scheme across the whole south west of England region because it benefits patients.

Ailsa Colquhoun spoke to Paul Foster, South Devon’s clinical director for pharmacy and prescribing, about the development

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A NHS South West is adopting a patient safety scheme for medicines following work that took place in four trusts as part of the “Safer patients initiative”. South Devon Healthcare NHS Foundation Trust, one of the four trusts, received a Pharmaceutical Care Award in 2008 for its work in improving medicines safety in secondary care.

The team approach to medicines safety is being rolled out across the region because it continues to benefit patients and improve patient safety, and has brought many professional rewards to the trust, says Paul Foster, clinical director for pharmacy and prescribing at South Devon Healthcare.

Thanks to the patient safety processes now embedded, the trust is well positioned to respond proactively to national patient safety initiatives such as those from the National Patient Safety Agency and the National Institute for Health and Clinical Excellence. The safety work has also placed the trust in a positive position in dealing with targets specified under the Commissioning for Quality and Innovation (CQUIN) payments framework.

There are further advantages for the trust’s clinical pharmacists, chiefly that the work has highlighted the value of medicines management within the trust. “More people now understand what medicines management is and what it does. They understand that a lot of things can go wrong with patients’ medicines. They also now appreciate the medicines management team has the skills to rectify these problems, once they are reported,” Mr Foster says.

Ongoing patient safety work

Among the new targets now being discussed by the medicines management team are a redesign of the processes that improve the provision of medicines information to high risk patients before discharge, and a reduction in the number of missed doses on the wards.

The team has also reviewed the secondary drivers for a safe medicines system, which has indicated that some further work is required.  There will be a resulting safety initiative to improve the reliable use of laboratory data when monitoring high-risk medicines and to improve the availability and use of specific guidelines associated with the reversal of potent medicines.

Mr Foster thinks the inspiration and tempo to continue to improve patient safety come from two main drivers: the benefits to patients seen so far and a Monday morning review and planning team meeting that is attended by the director of patient safety, hospital consultants, the clinical director and the pharmacy leads.

Success areas

South Devon was one of 20 trusts selected by the Health Foundation in 2007 to work with the Institute of Healthcare Improvement as part of the “Safer patients initiative”. Its work has, so far, concentrated on three main areas: improved anticoagulation, medicines reconciliation and venous thromboembolism prophylaxis.

Improved anticoagulation

Before the team’s work, less than 50 per cent of inpatients taking warfarin had a therapeutic INR (international normalised ratio) for more than 80 per cent of the time they were in hospital, and the number of errors in oral anticoagulation dosing was 30 per 1,000 doses. This has now been reduced to zero, and it is accepted that the inpatient prescribing and administration of oral anticoagulation is more than 95 per cent reliable.

Medicines reconciliation

Before the team’s initiative 40 per cent of patients had a prescribing error made on admission when compared with an accurate drug history. Medicines reconciliation is now reliable in over 90 per cent of patients admitted on Mondays to Fridays. This is monitored monthly through a sample chart review on all wards.

Venous thromboembolism prophylaxis

VTE prophylaxis in elective surgical patients has increased from below 20 per cent in 2006 to above 95 per cent in 2010. In addition, trust-wide VTE assessment and prophylaxis is now above 90 per cent.

Work has also been done to ensure that allergies are reliably recorded for all inpatients and a specific piece of work was undertaken in the paediatric unit to reduce the errors associated with paediatric analgesia.

Leading the way

Mr Foster describes the changes at the trust, and its new standing as a lead trust for patient safety, as “a highly rewarding experience”. He directly attributes the improvements seen in patient safety to the training and support the team has received from the Institute for Healthcare Improvement.

He believes the key to the successes lies in the IHI’s rapid cycle testing approach to implementation (plan, do, study, act). He says that this step-by-step approach ensures that small step initiatives are planned, executed and evaluated for reliability and practicality by all stakeholders, each step building on the one before, until the whole initiative is rolled out.

The IHI also provided training in understanding and using data to design reliable processes.

He says: “Ultimately, this succeeded where previous efforts had failed. Previously, we had tried to implement changes by simply agreeing guidelines and protocols and then expecting everyone to use them, but this just didn’t work.

“The IHI’s model allows stakeholders to identify and resolve problems, and ensure engagement right from the very beginning. This gives everyone the confidence to know that at the end they will roll out a successful initiative.”