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Improving drug chart documentation in elective surgical patient admissions.

ABSTRACT: National Institute for Health and Care Excellence (NICE) guidelines state that all healthcare organisations should put policies in place for medication reconciliation on admission. At Croydon University Hospital a medication history had previously been taken in Foundation Year 1 (FY1) preoperative clinics. However, when these clinics were deemed unnecessary, this opportunity for drug chart documentation was lost, along with an awareness of this responsibility among the FY1s. As a result patients were being admitted to wards without adequate drug chart documentation which resulted in a serious untoward incident occurring. This project aimed to increase awareness among FY1s of this responsibility and as a result increase drug chart documentation in postoperative elective surgical patients. The drug charts of 40 postoperative elective surgical patients admitted to all surgical wards were reviewed over a 2 week period. 12.5% (4/32) of patients taking regular medication had these correctly prescribed, with 'high risk medication omissions' found in 7.5% (3/40). Documentation of an allergy status was absent in 17.5% (7/40) of patients, including 5% (2/40) of whom had a known drug allergy. To create awareness of this responsibility, first, a presentation was given to the FY1s, second, posters to prompt action were placed on the elective surgical wards, and finally, the Director of Medical Education emailed the FY1s reiterating these facts. We then reviewed the drug charts of 45 elective postoperative patients over a 2 week period following these interventions. The results showed: correct prescription of regular medications improved to 48% (16/33); 'high risk medication omissions' reduced to 4% (2/45); documentation of allergy status on the drug charts increased to 87% (39/45); failure to document a known drug allergy on the drug chart fell to 2% (1/45); and patients with a 'high risk medication omission' or an undocumented known drug allergy decreased from 12.5% (5/40) to 7 % (3/45). This study has highlighted an area in which medication reconciliation and drug chart documentation were inadequate, and posed a risk to patient safety. Interventions designed to educate the FY1s and inform them of their responsibility improved standards in regular medication prescription and allergy documentation. However, leaving the onus with the FY1s was not enough to achieve adequate drug chart documentation. Further project cycles may therefore require the implementation of a step within the patient admission protocol in the preoperative ward that requires the nursing staff to contact the team's doctor when the patient arrives in hospital to ensure satisfactory drug chart documentation. In addition, collaboration with the pharmacists could also allow a 'best possible medication history' to be taken on the day of admission and thus reduce risk to patient safety.

SUBMITTER: Thompson A

PROVIDER: S-EPMC4663846 | biostudies-other | 2014

REPOSITORIES: biostudies-other

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Improving drug chart documentation in elective surgical patient admissions.

Thompson Alice A

BMJ quality improvement reports 20140218 2

National Institute for Health and Care Excellence (NICE) guidelines state that all healthcare organisations should put policies in place for medication reconciliation on admission. At Croydon University Hospital a medication history had previously been taken in Foundation Year 1 (FY1) preoperative clinics. However, when these clinics were deemed unnecessary, this opportunity for drug chart documentation was lost, along with an awareness of this responsibility among the FY1s. As a result patients ...[more]

PMID: 26732464

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Project description:Record keeping for patients on non-invasive ventilation (NIV) at St. Georges Hospital is poor. The initial NIV prescription is often not recorded, and changes to the NIV prescription or the rationale for the changes (ABG results) are also poorly documented. This leads to confusion for nurses/doctors as to what the correct settings are, meaning patients could receive ineffective ventilation. The use of NIV is also poorly recorded by nursing staff meaning that doctors are unsure if the prescribed NIV is being achieved. This can lead to treatment being escalated unnecessarily in the event of treatment failure. Non-invasive ventilation (NIV) is the provision of ventilatory support in the form of positive pressure via the patient's upper airway using a mask or similar device. NIV is indicated for treatment of acute hypercapnic respiratory failure, of which there are many causes, though COPD is the indication in up to 70% of cases.[1] British Thoracic Society (BTS) guidelines for NIV suggest that the rationale for commencing a patient on NIV and the proposed settings should be clearly documented.[2] Clinicians cannot effectively tailor changes to the patients NIV settings if this information is not clearly recorded, which could lead to increased time requiring NIV or NIV failure. Three main areas were considered important to measure for this project. The initial prescription of the NIV, changes to the NIV settings, and nursing documentation surrounding NIV. A baseline measurement of NIV documentation for two weeks found NIV documentation to globally very poor. NIV was formally prescribed 29% of the time, full detail of intended settings were documented 57% of the time, the decision to commence NIV was discussed with the respiratory consultant/SpR just 29% of the time and on no occasion was a decision regarding escalation of treatment recorded. Eighteen changes were made to the NIV settings. These were formally prescribed 22% of the time and detail of the intended settings was recorded 44% of the time. Nursing documentation included detail on the length of NIV use just 21% of the time, and comments on the NIV use were left just 33% of the time. The intervention was a unified four page NIV prescription chart. Page 1: An area for the NIV to be initially prescribed with reminder questions for important considerations. Page 2: An area for changes to be made to the NIV settings. Page 3: An area for the most up to date NIV/respiratory plan to be documented. Page 4: Nursing documentation, with prompts for the time NIV was put on/off and for comments. The chart was printed at St Georges print services and paid for by the respiratory ward. A further two weeks of monitoring followed after implementation of the new chart. Improvements were seen in all areas of documentation surrounding NIV. The NIV was formally prescribed 86% of the time compared to 29% pre-intervention. The NIV settings were stated 100% of the time in the initial prescription. An escalation decision was recorded 71% of the time. Changes to the NIV settings improved to 92%. Nursing documentation improved greatly. The length of the NIV use was recorded for 91% of NIV days compared to 21% previously (p<0.001), and comments on the use of NIV improved from from 33% to 98% (p<0.001). Cases where the documentation remained poor were in those patients for whom the new chart had not been used. The implementation of a unified NIV prescription chart to be kept in the bedside notes on the respiratory ward greatly improved documentation surrounding NIV. Further work must be done to ensure that the chart is used 100% of the time. This will include adjusting the chart to reduce the workload to use it, rolling the chart out on the acute medical ward, and submitting the chart to the trust board for its acceptance as an official trust chart.

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Dataset Information

Improving drug chart documentation in elective surgical patient admissions.

Publications

Improving drug chart documentation in elective surgical patient admissions.

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