Two innovative prescribing initiatives to reduce medication incidents

1 May 2012

Creative nursing approach to improving medication safety: Wairarapa DHB

Initiated by nurse educators and focused on medication prescribing standards, Wairarapa DHB has introduced a medication safety programme to ensure that when the new national medication chart was introduced, prescribing practice had already improved.

"We were aware of some poor prescribing habits, which we didn't want carried over to the new medication chart," says clinical nurse educator Lucy McLaren.

"They included handwriting not being clear, the number of units not being clear, times not being right, and allergies not being recorded. Nurses have to administer the medication and shouldn't have to try and interpret a chart."

Nurses were given the mandate from the director of nursing and chief medical officer to challenge poor prescribing and withhold the administration of medication unless it adhered to the top ten safe prescribing rules.

"We knew that some nurses felt they didn't always feel supported to challenge poor prescribing, so this was also an opportunity to address that," says Lucy. “The response to the new measures was generally very positive."

It clarified good prescribing practice ahead of the introduction of the new medication chart and gave doctors an opportunity to ensure their prescribing practice met the standards.

As part of this initiative, the nurse educators spent a morning a month in their red t-shirts, monitoring and conducting random checks on prescriptions and passing on any concerns about repeat issues to the CMO. Seeing the red shirts was a reminder to nursing staff to follow the new standards.

Sticking within the red tape

A simple square of red duct tape on the floor of a busy ward at Wairarapa Hospital is helping to improve medication safety.

At Wairarapa DHB, when two nurses are standing inside the red square by the controlled drugs cabinet, it’s a signal to their colleagues that they are not to be disturbed because they are totally focused on checking controlled medication before it’s given to a patient.

“Ideas like this work because they are generated so close to the clinical coalface,’ says Cate Tyrer, Wairarapa DHB director quality, safety & risk. “My challenge was to create an environment where quality improvement ideas like this would multiply and flourish.”

There was an opportunity to do just that when she chose to divide up a new quality leader role across nine key clinical areas, and instead of employing one person full time, split the role among some enthusiastic nursing staff with a passion for excellence and innovation.

Once a fortnight, the nurse quality leaders have a dedicated day away from their usual role to focus full time on quality improvement, and it’s been a great success.

“The amount of quality improvement and buy-in from clinical staff has far exceeded what could have been achieved by just adding an extra person to my team. While I might manage quality, the responsibility for it needs to come from within the clinical services teams.

“Everyone knows that every second Wednesday is that nurse’s day to focus on quality improvement. It’s protected quality time, paid from my budget. They don’t wear their uniforms and they can’t be pulled off their quality work just because the ward gets busy.”

She says all the nurse quality leaders have worked in their respective areas for some time and have the respect of their colleagues, so their suggestions are listened to.

“Of course, they are a catalyst for everyone to think about quality and safety more because they don’t switch off from it on the other days of the week.”

Complaints and negative patient satisfaction surveys are directed to the relevant quality leaders who look at what can be done to improve things.

Cate Tyrer and the quality leaders meet away from the hospital at the end of every fortnightly ‘quality day’ to discuss issues that have come up and improvement ideas. The red tape on the floor was just one of many ideas to come from the new approach.

“We’d been getting some drug errors in one of our wards – nothing that had caused harm to a patient, but things like missing signatures or other documentation errors. It’s a very busy ward and it can be very difficult for staff to focus because of all the distractions and interruptions. Two nurses standing in the red square in front of the drugs cabinet is a simple but effective cue to everyone that they’re not to be disturbed because they are double checking drugs.”

Since this system was introduced last November there has been a marked downward trend in medication errors.

Article contributed by Wairarapa DHB communications, originally published in 2012 HQC Sentinel Events report.