Collaborative working reduces errors
A collaborative working project at Luton and Dunstable Hospital has reduced
potential adverse drug events by 20 per cent in six months. The Department
of Health’s chief pharmacist and chief medical officer recently visited
the hospital to hear about the work.
Kate Jones, associate director, Luton and Dunstable, explained that the
collaborative method of working, which brings together teams from 26 departments
and wards across the hospital, is based on a successful technique developed
by the Institute of Healthcare Improvement in the United States. “Normally
this kind of working brings together groups from different organisations,”
Ms Jones said. “After attending a collaborative meeting in the US,
I felt that this could be applied within our hospital.” She added
that the aim is to close the gap between identified best practice and
what actually happens in the work place. This is done by testing out small-scale
changes and building evidence as the work proceeds.
At Luton and Dunstable, a baseline audit was followed by a series of
meetings for staff. These involved explanations and discussions together
with a social event and an overnight stay, designed to allow staff to
talk to members of other departments. After a period of “active testing”
further meetings were arranged to give feedback on ideas that had been
found to work.
Dr Mary Evans, acting chief pharmacist at Luton and Dunstable, said that
pharmacy staff have been involved in the meetings and in gathering data.
The pharmacy has completed two audits: one on drug storage on wards, the
other on the completion of the known allergies section on prescription
charts. “Failure to complete the allergies section was identified
as contributing to one of the top five potential adverse drug events.
We have found that the collaborative work has improved the rate of completion,
both by raising the awareness of other staff and through pharmacists taking
an active role in ensuring completion,” Dr Evans said.
Other common problems included drugs not being available on wards when
needed, doses being prescribed but not then administered and problems
with poorly completed prescription charts. Some of these were linked to
interruptions to drug rounds on wards and guidance is being issued to
patients and relatives about when to make enquiries to staff.
The Department of Health’s chief pharmacist, Dr Jim Smith, and chief
medical officer, Professor Sir Liam Donaldson, visited the hospital last
week to hear about the work. Ms Jones said that their attendance at a
meeting for staff has further helped to raise awareness of the collaborative
working. Dr Smith and Sir Liam were told that the number of actual and
potential adverse drug events has fallen from 1,404 in January this year
to 1,082 in July. In addition, there has been an increase in the number
of reports being made through the hospital’s clinical incident reporting
system, which Ms Jones said was a sign of a cultural change taking place.
After the meeting Dr Smith said that similar collaborative working is
being used in the medicines management pilots in primary care. Sir Liam
said that the collaborative working would be studied by the National Patient
Safety Agency. The Government has set a target of reducing adverse drug
events by 40 per cent by 2004.
|
