Presentation-9-Dolores

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Dolores Keating MPSI
Head of Pharmacy
From Pen to Patient:
Improving Prescription Writing Practice at a
Psychiatric Teaching Hospital
WHY PRESCRIPTION WRITING?
Medication errors are one of the most
common causes of patient harm1
Poor prescription writing is a factor
National and international patient safety issue
Baseline audits in Irish hospitals show
low rates of adherence to good practice
guidelines2-5
Quality improvement processes including audit and
feedback, educational initiatives, improving medication
charts and multidisciplinary working can raise standards3-7
Sustaining improvements is a challenge
1.
2.
3.
4.
NPS, UK, 2009 www.npsa.nhs.uk
Farooq et al, It J Med Sci, 2008; 177; 243-245
Ahmed a et al, Ir J Psych Med 2011; 28(2): 84-86
Tully et al, Ir J Psych Med 2010; 27(2): 82-85
5.
6.
7.
Bates et al, Ir J Med Sci: 2010; 179: 183-186
Dornan et al, EQUIP Study, 2009; www.gmc-uk.org
Health Foundation, UK, 2012; www.health.org.uk
AUDIT CRITERIA
•
Allergy documentation
•
Generic prescribing
•
Handwriting: written in block capitals or un-joined lower case
•
Start date
•
Discontinuation process completed
•
Patient name and MHIS number on each page (2012)
•
Prescribers signature bank and MCRN completed (2012)
PRN Medications
•
Dose specified
•
Interval specified with maximum frequency in 24 hours
•
Weekly review of PRN medications documented (2012)
SAMPLING
Every 4th name on an alphabetical list
25% of inpatient cohort over one week
N=40 to 50
Some standards may not apply to all charts e.g. if no PRN
medication prescribed
STANDARD
100% adherence within the entire chart with the criteria
Exceptions defined
• Brand name of a product that is not inter-changeable e.g. Priadel ®
• ‘nocte’ for frequency of hypnotic in PRN section
INTERVENTIONS
Pre-audit
Baseline
2010
Re-audit
2010
Re-audit
2012
Re-audit
2013
Re-audit
2014
•Introduction of a new medication charts
•Dissemination of Good Prescribing Practice Guidelines
•Intensive targeted feedback
•Good Prescribing Practice Education
•Review of Medication Chart
•Good Prescribing Practice Education Mandatory
•Pilot targeted feedback for PRN review
•Improved medicines reconciliation
•Targeted feedback for Prescribers Signature and PRN standards
•Format of Good Prescribing Practice Education Reviewed
Pharmacists
screening
medication charts
Reinforcement of
Standards
Medication safety
event reports
analysed
Dissemination of
Guidelines
Active and Passive
Feedback
TARGETED FEEDBACK
TARGETED FEEDBACK
EDUCATION
REVIEW OF MEDICATION CHART
Draft HSE/State Claims Agency/Mental Health Commission
Guidance for design & Governance of the Mental Health inpatient Medication Prescription & Administration Record
(MPAR) 2012
National HSE MPAR Guidelines for Acute Hospitals 2012
Standards for the design of Hospital in-patient prescription
charts UK: Academy of Medical Royal Colleges, Royal
College of Nursing, Royal Pharmaceutical Society UK
National In-patient Medication Chart Standards, Australia
PROMPT TO CLARIFY TIME OF
ADMINISTRATION
PROMPT FOR REWRITING CHART
DURING NORMAL WORKING HOURS
LAYOUT OF PRN SECTION
LAYOUT OF PRN SECTION
SUPPLEMENTARY CHARTS
MEDICINES RECONCILIATION
Allergy documentation
RESULTS
Baseline
100
90
80
70
60
50
40
30
20
10
0
Baseline
RESULTS
100
90
80
70
60
50
40
30
20
10
0
Baseline
2014
RESULTS
100
90
80
70
60
50
40
30
20
10
0
Baseline
2010
2012
2013
2014
CHALLENGES
Labour intensive
Turnover of medical staff
Sustainability
Audit standard
Passive dissemination of guidelines and feedback
Different prescription charts and guidelines across the
mental health services
WHAT WORKED?
Improve prescription charts
Prescription monitoring by pharmacists
Medicines reconciliation
Audit and active feedback
Education
Multidisciplinary working
Leadership
Support at governance level
Patient safety culture
WHERE TO NOW?
Medicines Management in Mental Health
Education
National Guidelines
Electronic Prescription Writing
THANK YOU
Cathy Shelley
Stephen Boss
Brid O’Meara
Ruairi Corkery
Aoife Davis
Audrey Purcell
Lorna Dillon
De Abbie Lane
Dr Susan fletcher Jones
Dr Rory Shelley
Dr Stephen McWilliams
Dr Brendan Cassidy
Caroline Hynes
Aoife Carolan
Ciara Dowling

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