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Transcript of original MAHSC
We found variation in the following areas:
Number of wards collected on
Day of collection
Data use ( or lack of) for feedback to staff
Pinpointing poor practice
Large variations in omissions data - also reflected in previous research rates:1.4%-20%. (Baqir, 2015)
E.g. SRFT are using on 10 wards in the hospital whereas UHSM have scaled up to 11 but not the whole hospital yet - CMFT 11 wards, want to swap a different set of wards.
Lack of engagement
Links to ownership
'Fighting' to use the tool, despite the capacity issues
Financial incentives: Choosing to use as a local CQUIN
Measurement of the impact of improvement activity on medication safety...
Data provides a baseline that did not exist previously
In turn improving reporting culture (See example 1 above)
The reporting rate helps measure the culture (Grissinger, 2009)
E.g. SRFT omissions data had improved since the introduction of a "clinical pharmacy team" pilot
Focus on process measures...
Some places only using Step 1 and 2, with focus on potential errors.
Lack of understanding about how step 3 works
E.g. CMFT are not using step 3 (triggers) because it is covered by incident reporting system and thought it would be difficult to arrange an MDT meeting.
Other Improvement work included:
"Zero tolerance" campaigns for omissions
"Zero tolerance" campaigns for completion of medicines reconciliation
"Find-a-drug" flowcharts to reduce omissions
Implementing MDT huddles for Step 3
Website traffic and related input problems
Funding e.g. Sourcing iPads
Views on Capacity
Awareness/reluctantance to use personal phones
variation in use
collecting data and not using
difficulty using new version (accounts for dips in Aug 14 but this was rectified through SUCCESFUL additional training via phone calls and WebExes)
1) Increased feedback of data to teams
2) Support for champions
3) Further sharing of improvement work
4)Development of Case studies for positive practice
5) Standardised training opportunities should be provided
6) Encorporation into Medication Safety Officer role
7) Development SOPs for data collection
8) Scaling up use of the MedsST to all wards
9) Protected time for data collectors to reduce interuptions
10) Providing further quality improvement training as incentives
Leading to sharing of other Improvement work and structure measures...
Range of staff involved included:
Ward Manager Nurses
Quality improvement team
E.g. Nursing staff reported they had worked with Pharmacists much more than they did prior to using the Medication Safety Thermometer
UHSM have fought to be able to use iPads for data collection - this has halved data collection time. But there is still issues with data collectors not able to use the iPads.
To explore and understand the "story" behind the MedsST data collected by MAHSC organisations.
Haelo analysts reviewed data from Oct 2013 - July 2016 from three MAHSC organisations
Using the "5 Whys" model we realised that we needed to first explore how the MedsST is being used.
Meetings with MedsST users from each of the three MAHSC organisation were conducted.
Findings compiled for feedback and learning purposes.
We spoke to a wide range of NHS staff:
Audits (predominantly yearly)
Using the Medication Safety Thermometer in conjunction with existing tools
Safety Thermometers are designed to be used alongside local measurement systems (Power, 2014).
E.g. UHSM Datix reports have increased since using the MedsST (due to other Medication safety initiatives also)
The measurement of medication safety before...
Bridget Armour and Paryaneh Rostami
Behind the MAHSC: Exploring the narrative behind the Population Health and Implementation targets for medication safety
Lee Bennett (Charge Nurse on ward B1)
Pete Robertson (Pharmacist)
Jane McCann ( Pharmacy Governance Manager/ Technician)
Belinda Ettles (Pharmacy technician overseeing MedsST )
Paul Griffiths (Medication Safety Officer)
Emma Howlett (Medicines Governance Pharmacy Technician)
Ownership and Leadership...
More than one champion at each organisation.
3. Triggers of harm
Excluding Valid clinical reasons, a reduction of 20.7% has been seen in MAHSC organisations over three years.
Measures whether Medicines reconciliation was started within 24 hours of patient admission. An improvement of 7.8 % in MAHSC organisations over three years observed
This step is not fully being used by all organisations. An increase of 84%, from 1.9% to 0.3% has been seen but this is probably due to lack of reporting rather than improvement.
Thank you to the Haelo Measurement team for analysing data, Catherine Qualtrough for proofreading the associated report, and the participants from all organisations for meeting with us.
Thank you for listening.
, M. et al. (2009). Measuring up to Medication Safety in Hospitals. Medication Errors. 34 (1), 10.
, M. et al. (2009). Learning from the design and development of the NHS Safety Thermometer. Int J Qual i Health C. 26 (3), 287-297.
, W. et al. (2015). Reducing unacceptable missed doses: pharmacy assistant-supported medicine administration. IJPP. 2015; 23:327-332
EN, et al. (2008) The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17:216-23.
It was clear that strong leadership was needed to engage staff and encourage ownership of medication safety. This often lead to increased further improvement work and pro-actively learning about and sharin about positive practice.
E.g. UHSM's MSO implemented "find-the-drug" omissions charts after learning about them from another organisation.
Although not the MSO at this organisation. Pete had taken it upon himself to take some responsibility for MedsST data collection with nurses, analyse data and engage in further improvement and research about the Medication Safety.
Although Steve has left UHSM, his legacy of championing the MedsST was evident. Not only at UHSM but at NHS England, with whom he haen on secondment. For example, Steve had fought to engage nurses with the MedsST and continue to focus on triggers of harm and introduced "find-the-drug" flowcharts,
CMFT lacked a site-wide MedsST champion, which may have been due to the fact data was collected by pre-registration pharmacists who are temporary staff. This may have caused a lack of ownership and therefore a lack of engagement. The Pharmacy technician Emma Howlett was trying to champion use and expand use to other wards, however further support was required.
Steve Williams: Consultant Medication Safety Pharmacist
Pete Robertson: Band 8 hospital and GP practice pharmacist
10% of patients are harmed by healthcare
15% of this = Medication related
MUST measure to improve
Workstream 2: Reducing errors attributable to medicines management
Hidden champion: Wards AM3 and AM4