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Version 2! - Harm Free Care

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George Eliot Hospital NHS Trust
Medication Safety Thermometer
Elizabeth Holland
Clinical Audit & Effectiveness Nurse
George Eliot Hospital NHS Trust is a District General Hospital in Nuneaton
320 Beds including Maternity
1,580 staff
Took part in the testing of Safety Thermometer
Started M.S.T in September on one medical ward – Elizabeth 27 beds
December
2 medical wards – Melly & Elizabeth
2 surgical wards – Victoria & Alexandra
January
1 medical ward – Bob Jakin
September we used the 3 page tool from Haelo
October I adapted the input sheet from Haelo to
test
STEP 1
STEP 2
Omissions in last 24 hrs 1.6a
Patient ID
Gender Age
1.1
1.2
Allergy
Meds
Reconciliation
Status
Prescribed
1.4
1.3
1.5
Valid
Clinical
Reason e.g
Number low BP
Route Not
Available
(e.g NBM,
Outstanding
Med Not IV line
Reconciliation Avail
tissued)
Patients
Absent Patient
at Meds Refused
Round
Dose
Omitted dose critical meds 1.6b
Other
(put
Not Doc code)
AntiAnticoag Opiate Insulin effective
High risk meds 1.7
AntiAnticoag Opiate Insulin effective
Anticoags 2.1
Opiates 2.2
Injectable Sedatives 2.3
Insulin 2.4
Admin 10Resps
50% IV
Admin of below Common Admin of
Common Dextrose,
Flumazenil comp
glucagon
VTE bleed Admin Vit K INR >6 Naloxone 12bpm comp
Version 1 – same method as GEH Safety Thermometer
Found it over complicated even using the 3 page guide as reference
Ward:
Hospital Number:
M
Version 2!
Gender
Patient's gender
F
<18
Age
19-40
Patient's age
41-69
>70
Y
Is the allergy status documented?
Inc NKDA on kardex
N
I decided to go back to one form per patient
Printed double sided to cut down on paper
Tested in November on 3 wards – 5 patients
Used 3 page tool as reference guide
Was medicine reconciliation for all medicines started
within 24 hrs of admission
No - patient within 24hrs
Pharmacist has been involved
N
0
How many regular medicine are prescribed?
Omitted dose of regular medication in the last 24hrs?
Omitted doses a critical medicine
General comments from ward manager,
sister & pharmacist were positive
Y
Has the patient received any of the following
medicines in the last 24hrs
1-4
Not inc PRN, Stat doses, IV fluids, O2, food supplements or devices.
Different doses of the same medicine count as one medicine
5-15
>15
Insert number
Reason for omission
Anticoag
Opiate
Insulin
Anti-effectives
Anticoag
Warfarin
Exclude Food supplements & O2 insert number of omissions using
available info e.g. 3 omissions as pt refused & 2 route not available
Number of omissions of a critical medicine
Anticoags (Heparin, LMWH [excluding VTE proph], Warfarin &
NOAC's) Opiates (exclude oral codeine & dihydrocodeine IV or SC
sedatives, Insulin)
Opiates
IV/SC Sedatives
Insulin
If YES proceed to Section 2
Amendments have been made to Version 2
after discussions at the Webex & with Haelo
Anticoag
Heparin, LMWH, Warfarin & NOACs
Y
Potential for bleed, interactions with other medicines
N
Any bleed or any kind of VTE
Administration of Vit K, Protamine or clotting factors e.g. Octaplex
INR greater than 6 or APTT ration greater than 4
Opiates
Y
Admin of Naloxone
Common complications of Opiates include sedation, respiratory
depression & confusion
Reps rate below 12bpm
N
Injectable Sedatives
Common complications
Admin of Flumazenil
Midazolam, Lorazepam,, diazepam, clonazepam
Y
Common complications of over sedation include hypotension, delirium,
respiratory depression, reduced GCS
N
Insulin
Y
Common complications (capillary blood sugar <4mmol/L) or symptoms of hypoglycaemia
Admin of reversal agent for hypoglycaemia (10-50% IV Dextrose, Glucagon)
Symptoms of hypocaemia including anxiety confusion, extreme
hunger, fatigue, irritability, sweating or clammy skin, trembling hands
N
Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycaemisc State (HHS)
Auditor (print name):
Date:
Version 4!
Collection form Libby Style!
Alterations to make it suitable for
other organisations
The collection form has now been
developed into a tool for the Acute and
community to test in January 14
Next steps?
Sharing results
The Band 7 on Elizabeth observed the
first collection and asked to see their
results. Pharmacist assisting the
collection also interested in findings.
Ward Dashboards
To make the data look the same as classic Safety Thermometer I have put
ward level data in a dashboard to share
[email protected]
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