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NHS Tayside - Safer Patients Storyboard Template Kick off LS


									               NHS Tayside
        Aims and Programme Goals
   Mortality: 15% reduction
   Adverse Events: 30% reduction
   Ventilator Associated Pneumonia: 0 or 300 days
   Central Line Bloodstream Infection: 0 or 300 days
   Blood Sugars w/in Range (ITU/HDU): 80% or > w/in
   Staph Aureus Bacteraemias: 30% reduction
   Crash Calls: 30% reduction
   Harm from Anti-coagulation: Reduction in INRs > 6
   Surgical Site Infections: 50% reduction in population of
   All process measures will be > 95% reliable


Scottish Patient Safety Programme Critical Care
                 Driver Diagram
Outcomes              Primary Drivers         Secondary Drivers
                        Processes, Rules of      Components, Activities
                        Conduct, Structure    Reliable Process of Care:
                                              • Prevent ventilator complications
                      Provide reliable,       • Prevent CL complications
                      timely, care using      • Prevent Inf. & cross contamination
                      evidence-based          • Proper Sepsis Rec. and Rx
                      therapies               • PVC Bundle

                       Integrate patient      Communications Team & Family
                        and family into       Clarify care wishes and EOL planning
 Patient                     care
                                              Appropriate Infrastructure to Provide
Outcomes                                      Reliable, Evidence Based Care
(Reduced Mortality,   Develop
Infections, & Other   infrastructure that     Improve ICU throughput
 Adverse Events)      promotes
                      quality care            Competent staff with knowledge in QI
                      Create a                Reliable planning, communication
                      collaborative team      and collaboration of a multi
                      and safety culture      disciplinary team
    Repeated Use of the PDSA Cycle

                          Reduction in Central venous catheter infections

                           30% reduction in SAB infections by January 20011

                             Introduction of a tested and compliant CVC maintenance
                             bundle within the Medical HDU in Ninewells.

                                            Test 4 – new individuals successfully
                                            assessing compliance to ensure a variety
                                            of compliance perspectives

                                Test 3 – individual elements of the bundle tested
                                successfully over subsequent months showing
                                continued compliance.

                Test2 – Following methodology rapid spread throughout unit
                of maintenance bundle.

Test 1 - Central venous Catheter maintenance bundle introduced to Medical
HDU Ninewells with one nurse and one patient. No clinical trolley available
so staff using patient bed table. Trolley purchased and re tested.
Repeated Use of the PDSA Cycle
                 To implement the Peripheral vascular cannula (PVC) Bundle within
                 Intensive care Unit in Ninewells Hospital

                   95% compliance with PVC bundle and SPSP 30% reduction in
                   related Staphylococcus Aureus bacteraemia

                    Change current practice to improve the compliance with the
                    PVC Bundle
                    Test idea and spread PVC bundle in ICU Ninewells

                                 Test 3 – As well as monthly random audits
                                 with compliance, senior nurse now reviews
                                 all bundle documentation nightly, which has
                                 shown further significant compliance.

                Test 2 – Compliance improving but introduction
                of daily spot checks of bundle by 2 members of
                staff initiated to raise profile.

 Test 1 – Bundle tested on patient with one nurse but
 documentation unclear. Issues raised and changes made.
 Discussions initiated empowering staff to remove
Repeated Use of the PDSA Cycle
                     Implement changes to our Ventilator Acquired Pneumonia
                     (VAP) Bundle

                     Achieve 95% compliance with VAP Bundle
                     Achieve SPSP goal of zero incidences in 300 days.

                     Change current practice to include the use of Chlorhexidine
                     gel prior to intervention with ventilated patients.

                                                 Test 3 – change in practice
                                                 shows larger decrease in
                                                 reduction of VAP within ICU at
                                                 Ninewells. Element now added
                                                 to the existing IHI Ventilation

                       Test 2 - Introduction of chlorhexidine gel prior to
                       intervention with ventilated patients. Finalised
                       protocol tested on 2nd patient then protocol shared at
                       Multi professional awareness sessions.

  Test 1 - Full compliance with VAP bundle but little reduction noted
  in VAP. Gel was tested on one patient. Agreement then reached
  as to definition of what constitutes a ventilated patient prior to
Introducing Changes to the VAP Bundle within ICU Ninewells

Following using IHI improvement methodology the full VAP bundle was successfully
implemented within ICU at the Ninewells site. Improvement is recorded over a significant
period of time but with a slowly decreasing trend. The wider team agree to test adding
Chlorhexidine Gel to increase the reduction of VAP.

Having tested this on one patient with one nurse, there is then Staff discussion and
consensus around the definition of what constitutes a ventilated patient for the purpose of
the test, and this is written into the unit protocol.

The new protocol is tested on a second patient successfully, and is therefore spread
throughout the unit quickly using improvement methodology. The protocol is introduced to
the wider Multi professional team through staff awareness sessions.

Following the introduction of the new VAP protocol and Bundle there is a marked sustained
reduction in VAP in ICU Ninewells.
Implementation of the CVC maintenance bundle within medical HDU Ninewells

In an effort to reduce central line infections within the Medical HDU the CVC maintenance bundle was
introduced testing with one nurse and one patient. Although technique was compliant with the
bundle, a vital piece of equipment (a clinical trolley) required to be purchased to ensure that there
was the maintenance of a sterile field.

From this further testing of the bundle, following staff awareness sessions, allowed a quick spread of
the methodology and 95% compliance.

To ensure full compliance with the bundle on a monthly basis, the senior nurses within the HDU
observed different elements. This has given staff a clear focus in maintaining the high standards
already set.

Presently this was initially a person dependant system but now all members of staff are being
supported to observe practice to give an objective balanced peer perspective to the monitoring and
compliance with this bundle.

Implementation of the PVC bundle within ICU Ninewells

The PVC Bundle was tested on one patient with one nurse using PDSA. Following
feedback, discussions were initiated around the quality of the nursing documentation (to
which changes were made) and encouraging empowerment nursing staff to remove the

Following this discussion compliance improved. This was also then supported with the
introduction of daily spot checks of the bundle by 2 members of staff initially to raise its
profile within the unit.

The introduction of this practice has ensured maintenance of the established levels of
compliance within the department and effectively contributed to the reduction of PVC
related SAB.

                 Oral hygiene element of VAP
Implementation   bundle implemented
of daily goals

   ALISON INSERT HERE                             304 days since last

           Implementation of daily goals   Oral hygiene element of VAP
                                           bundle implemented
           Scottish Patient Safety Programme
             General Ward Driver Diagram
 Outcomes           Primary Drivers       Secondary Drivers
                                          *Early warning system (EWS) to identify
                    Provide reliable,      patient deterioration
                                          *Early response system (Outreach or
                    timely, care using     Rapid Response Team (RRT)) to
                    evidence-based         respond to deterioration
                    therapies             *Prevent healthcare associated
                                           infections, pressure ulcers
Improved general    Create a               PVC bundle
ward outcomes       collaborative team     Hand Hygiene practices
(Reduced            and safety culture     *Reliable planning, communication and
infections,                                collaboration of multi disciplinary team
crash calls,                              Involve Pt./family into goal setting
pressure            Ensure patient and    Open communication team & Family
ulcers, AE in CHF   family centered       Clarify care wishes and EOL planning
and AMI patients)                         Ensure patients physical comfort

                    infrastructure that   Optimise transitions to home or other
                                          facility (CHF,MI)
                    promotes               Optimise flow & efficiency in admission
                    quality care          process, handoffs, discharge process, care
                                          for high volume conditions (CHF,MI)
PVC Bundle, Orthopedic Ward - PDSA Cycle

                               Implement PVC Bundle all Wd 16 patients Ninewells Hospital

                                  95% compliance with PVC
                                  Bundle Process

                                    Adapt and test existing PVC Bundle process
                                    from SPSP to suit within ward 16

                                                    Test collection of date and audit
                                                    regarding compliance

                                     Continue to test with all patients and
                                     involving all staff

                    Adapt bundle and test with 3-5 patients and 3 nurses

  Test suitability of PVC Bundle to be used within orthopedic
  clinical setting with one patient and one nurse
SEWS, Angus Community Hospital - PDSA Cycle

                        Implement SEWS Chart Brechin GP Ward

                         95% compliance with SEWS and early
                         identification of patient deterioration

                           Adapt and test existing SEWS process from other areas
                           to suit within Community Hospital e.g. local algorithm

                                             Tested SEWS chart on staff
                                             redeployed from local ward that
                                             provide cover

                               Tested Algorithm with one call to Out of Hours

                Revised Algorithm then further testing with 3 then 5 patients
                and revised protocol with staff to ensure chart fit for purpose

   Test suitability of SEWS Chart within Community
   Hospital with one patient by one nurse
Safety Briefings, Perth Community Hospital - PDSA Cycle
                               Implement daily Safety Briefings within
                               St Margaret's Community Hospital

                                 95% compliance with Safety Briefings
                                 including Multi Disciplinary Team (MDT)
                                  Adapt and test existing Safety Briefing process
                                  from other areas to suit within Community Hospital

                                                     Test that members of the MDT
                                                     are aware of White Board and
                                                     importance information displayed

                                       Test that staff on each shift check and
                                       initial White Board ensuring compliance

                       Test that new safety issues are appropriately
                       added to White Board

           Test staff awareness of new system (White Board)
           of where to locate and read safety notices
Hand Hygiene, Medicine for the Elderly - PDSA Cycle

                                Hand Hygiene reliable in Wd 5 RVH
                                with 30% reduction in SABs

                                  95% compliance with Hand Hygiene compliance
                                  within the ward and reduction in SABs
                                    Adapt and test existing Hand Hygiene audit
                                    tool from other areas to suit within the ward

                                                      Re-test staff compliance for
                                                      Hand Hygiene using best
                                                      practice when washing hands

                                        Test staff that their Hand Hygiene method
                                        and practice used meets current best practice

                        Test staff in correct use of audit tool for
                        measuring Hand Hygiene compliance

         Test staff knowledge of reason for
         Hand Hygiene in relation to SABs and HAIs

Replacing the existing documentation currently in use within ward 16 regarding PVC post
insertion care with the SPSP PVC Bundle would allow for a uniform NHST wide format. The
documentation previously in use on the ward had been developed due to high risks of HAIs
and their impact because of the type of surgery delivered within ward 16.

Initial testing looked at the suitability of the new bundle for use within the ward and in particular
the Integrated Care Pathway (ICP) currently utilised within the ward. This was initially done with
one patient and one nurse before being tried with 5 patients and 3 nurses.

Testing was done to ensure all staff were aware of the planned change of documentation within
the ICP before implementing across the entire ward.

Compliance and how data was gathered was then tested to ensure reliability of the information
being gathered and that compliance rates were being met.
          GENERAL WARD

Daily electronic handovers were already part of the nursing culture, however to increase the reliability and
increase dissemination of the information the Senior Charge Nurse wanted to introduce a system that
would involve all of the Multi Disciplinary Team, support staff and GPs.

A white board was placed within the nursing office with relevant, concise and precise details written upon
it. Awareness systems were conducted to ensure with all staff as to how the system would be
implemented and maintained.

The first test involved ensuring that all the appropriate safety issues were visible. Subsequently testing
was carried out around the updating of information on the board. Relevance etc.

Compliance was tested next by asking all staff on a shift by shift basis to initial that they had read and
understood the information on the board. This was further supported by identifying two champions who
further tested that information continued to be updated and that all staff were initialling that they had read
the board.

The next test involved rolling out the process to all the support staff and members of the MDT.

To ensure that the safety issues were relevant spot audits were carried out by the designated champions

SEWS charts are now an integral component of how care is delivered within the Acute setting, its
integration within the community hospital setting is seen as the next logical step. Education for the staff
around use of and background to the development and use of SEWS was the first part of process.
After testing with one patient and one nurse it was noted that the algorithm used within the acute
setting did not suit the environment and conditions found within the community hospital setting.

The algorithm was reviewed and revised by staff and then further testing was undertaken with the new
format with 3 patients and 3 nurses. Further discussion with staff around implementing SEWS chart
throughout the ward highlighted pockets of limited knowledge and lack of confidence with using SEWS
across the ward. Further targeted training and education addressed this issue and SEWS were
implemented across the ward.

With HCA‟s an integral part of care provision delivery within the ward, they were trained in a similar
fashion to the qualified staff in the use of SEWS charts including determining criteria as to how and
when to notify qualified staff of any changes in a patients SEWS score.

Staff from local wards often assist on the GP ward and using lessons learned from the process of
introducing SEWS training of likely relief is presently being undertaken.
              GENERAL WARD
              KEYS TO SUCCESS

Good hand hygiene was recognised as being a vital component in preventing the contracting and
spreading of SABs and HAIs within any clinical setting. The first step undertaken within the ward was
testing the staff‟s existing knowledge around infection control and hand hygiene in particular. This
involved the Infection Control team who also delivered education for all of the ward staff around this

Testing of the observation tool used in auditing of Hand Hygiene opportunities highlighted that there
was not a uniform understanding of what represented and „opportunity‟. Further education and
clarification on the tool itself eliminated this as an issue.

Further testing of the audit tool threw up discrepancies in hand washing techniques used by staff
underlining that current best practice was not being used 100% of the time which could affect both
effectiveness and in measuring compliance.

Again education was undertaken around current best practice and estates where asked to replace any
taps at the sinks that required staff to touch with just washed hands.
Run charts demonstrate that compliance is meeting the minimum standard within the ward and that
C-diff rates have been positively affected.


              Testing of algorithm of
              acute services            Staff unfamiliar with use of

                        Audit tool tested

Staff education in
hygiene provided
by Infection
Control                                                Staff issues resulted in deployment
                                                       of relief staff unfamiliar with

                                            Dressing not
                                                                                       Dressing not

                                                              Dressing not

             Scottish Patient Safety Programme
         Peri-operative Management Driver Diagram
 Outcomes             Primary Drivers              Secondary Drivers
                         Processes, Rules of            Components, Activities
                         Conduct, Structure
                                                   Prevent Surgical Site Infections
                      Provide appropriate,         Ensure proper prescribing and
                      reliable and timely care     administration of prophylactic antibiotics
                                                   Ensure, if hair removal was required,
Improved peri         to patients using
                                                   operation site is clipped, not shaved
operative             therapies to prevent         Maintain normal blood glucose level (for/
                      surgical site infections     known diabetic patients)
outcomes                                           Ensure normal body temperature (excludes
(Reduce peri-                                      cardiac patients)
operative adverse
                      Create a team culture        Use briefings
events: infections,
                      attuned to detecting and     Use standard intra-operative procedures to
cardiovascular                                     prevent AEs
                      rectifying intra operative
events)               errors                       Undergo team training
                                                   Maintain team focus during surgery
                      Provide appropriate,         Have responses to intra-operative adverse
                      reliable and timely care     events ready
                      to patients using
                      evidenced-based              Identify patients at risk
                      therapies to prevent         DVT prophylaxis
                      peri-operative               Continuation of beta blockers
                      cardiovascular events
Repeated Use of the PDSA Cycle

                         Implement World Health Organisation (WHO) Checklist in
                         one theatre for one month.
                          95% compliance noted with use of checklist in
                          one theatre.

                           Adapt and test WHO checklist to Changes That Result in
                           Improvement suit theatres within NHS Tayside

                                          Test 3 – Challenges remain in relation
                                          to compliance with use of the
                                          checklist. Issues emerged when trying
                                          to use this checklist to eliminate all
                                          other checklists in wards and
                                          theatres. Testing continues.

                       Test 2 – Issues with checklist following the process of
                       patient from ward to theatre. Some parts of the ward
                       checklist not completed. Suggested changes made to

    Test 1 – Checklist tested on one ward, one patient and one theatre in
    Ninewells. This test showed that the checklist does not follow the
    patients’ journey and the form was then segmented into ward and
    theatre journey for suitability.
      Repeated Use of the PDSA Cycle

                                          Implement peri operative safety briefings within ADTC at
                                          Stracathro hospital
                                         There is 95% compliance noted with safety briefings.

                                         Change current practice to improve the exchange of
                                         important patient safety information

                                                              Test 5 – plan to spread testing of Safety Briefings with
                                                              all staff present in anaesthetic room to 4 consultant
                                                              surgeons and 4 consultant anaesthetists (3 specialties)
                                                              with patients being sent for, checked in, and held in
                                                              reception prior to the Safety Briefing staring therefore
                                                              preventing any delay to list start times

                                                          Test 4 – re-testing of Safety Briefing with all staff
                                                          present in anaesthetic room with 2 consultant
                                                          surgeons and 2 consultant anaesthetists (2
                                                          specialties) – currently being led by nursing staff –
                                                          this is still likely to present a delay to list start times
                                       Test 3 - SCN and 2 Senior Theatre nurses or designated deputy (1 Scrub/1
                                       Anaesthetics/Recovery) meet for daily meeting to discuss staffing, staff
                                       allocations, patient cancellations, list order changes, equipment issues,
                                       other work commitments etc – information disseminated to individual
                                       theatres, and incorporated into Safety Briefing.

              Test 2 – testing of a modified Safety Briefing following discussions with senior
              theatre management staff – tested and implemented a revised and agreed to Safety
              Briefing with staff available, then disseminated to key personnel within the relevant
              theatre team – no delays to lists starting.

Test 1 – testing of Safety Briefing with all team present – unsuccessful as unable
to get all team together – waiting for all staff to attend, inclusive of medical staff,
resulted in significant delays to the start of the list.
        PERI OP
Implementation of WHO surgical checklist within Main theatre suite at Ninewells

With the introduction of the World health organisation peri operative checklist, it was tested for its
suitability within one theatre, one ward with one patient and one nurse. Multi professional feedback
was welcomed and changes to the checklist were initiated for retesting.

Further feedback at second retest identified more changes were required to the checklist due to
inconsistencies in the quality of the documentation on completion.

The value of Multi professional feedback is key to the success of implementing this checklist within
the main theatres as testing currently continues.
     PERI OP
Peri operative Safety briefings in Stracathro Hospital

In an effort to improve theatre planning, theatre efficiency, peri operative communications and
team cohesiveness, the Daily Meeting was introduced to give an overview for the day. Team
Leader Meetings and Staff Team Meetings fortnightly have also been introduced to allow for more
effective theatre planning, improve communications and disseminate information.

A 3-point Safety Briefing was successfully tested and implemented, with agreement from theatre
management. This involved the Anaesthetist and Anaesthetic Nurse meeting, the Surgeon and
Scrub Practitioner meeting, then the 2 teams disseminating the information to each other - this
resulted in no delays to the lists starting.

With more understanding of and involvement in SPSP, nursing staff are leading testing of the
Safety Briefing with all staff present in the anaesthetic room - this is currently being tested with 2
consultants and 2 anaesthetists.

To prevent any delays to the start of the list, theatre nursing staff redesigned and redecorated
the theatre reception area, and each theatre anaesthetic nurse will send for the patient, check
them in and then hold them in the reception area while they attend the Safety Briefing.

The application of IHI improvement methodology has allowed the team to customise current
documentation being used on sister sites for their own use.

    Safety briefings                       Safety briefings
    performed, however,

                                           performed, however,
    not supported with                     not supported with
   completed                              completed
    documentation                          documentation

                 Documentation not   Documentation not
                 completed           completed

Documentation not
completed                                   Documentation not

                        Documentation not
                       completed

    Documentation not
    completed                                  Documentation not
                        Documentation not
          Scottish Patient Safety Programme
             Leadership Driver Diagram
 Outcomes       Primary Drivers         Secondary Drivers
                  Processes, Rules of        Components, Activities
                  Conduct, Structure
                                        Establish an SPSP Implementation Committee
                                        Ensure a feedback mechanism for issues
                                        raised in Walk-rounds
                Develop the             Ensure the development of a measurement
Provide the     infrastructure to       system used to understand and drive patient
Leadership      support quality and     care quality and safety indicators
                safety                  Assign a senior leader to each work streams
System to
Support the                             Meet with the Programme Manager remove
Improvement                             barriers
                                        Meet regularly with the SPSP Implementation
of Safety and   Provide oversight       Committee to track progress and remove
                to programme            barriers
Quality                                 Display the Gantt chart that depicts progress
                                        towards SPSP goals
Outcomes in      Promote the
your Board       position of safety     Ensure that the senior team participants in
                 and quality in the     Place safety and quality issues at the top of
                 organisation           senior leader meetings agendas
                                        Add SPSP progress and outcomes to the
                                        Board agenda
Patient Safety leadership Walkrounds - PDSA Cycle

                            Spread of Patient safety Leadership walkrounds within NHS
                            Tayside across all services by Dec 2009

                               Achieve 100% completion of action identified within
                               specified time scale
                                 Adapt and test existing walkround process,
                                 including tracker of actions and involvement
                                 of Non Executive members

                                                 Pre walkround briefing included
                                                 explanation of non- executive role
                                                 within the process and how and why
                                                 actions are tracked (not all staff aware
                                                 this is an SPSP outcome measure)
                                 Increase in actions completed as a result of
                                 previous test, however more realistic time scales
                                 are required on certain actions i.e. estates issues
                  Testing of tracker process which involves contacting the ward at
                  given time periods via email to gather updates on action progress,
                  executives are copied into these emails along with given timescales.

    Test the involvement of one non executive Board member one walkround.
    Successful, Board member to feedback process to other Board members and
    future dates circulated to all non-executive members
             KEYS TO SUCCESS

   NHS Tayside senior leaders have embraced patient safety as a strategic priority. This is demonstrated in a
   number of ways; commitment from both executive and non-executive Board members in the safety
   leadership walkround process. Prior to each walkround a briefing takes place with the executive team
   members and the representative from Safety Governance and Risk. This gives the opportunity to discuss
   previous visit reports and patient safety data collected as part of the SPSP.
   Walkrounds are now attended by non-executive members of the Board. Feedback has been extremely
   positive and is discussed at the NHS Tayside Board meetings.
   Improvements have been made to the tracker system for actions identified on the walkrounds and as a
   result we are showing an increase in number of completed actions per month. This data is shared at the
   monthly patient safety update with the Executive Management Team.


   The sponsors play a key role in ensuring patient safety is seen as a strategic priority and have been active
   in ensuring patient safety is integrated into the new organisational structure. The Patient Safety
   Development Manager meets with the sponsors on a monthly basis prior to the Executive Management
   Team Meetings to discuss successes and challenges within each workstream.

A robust system from ward to board has enabled the organisation to link process and outcome patient
safety measures i.e. run charts at the frontline, use of driver diagrams for monthly executive safety
updates, use of SPSP assessment scale to open all patient safety reports


To support the integration of patient safety and improvement methodology sessions have been delivered to
new managers and senior leaders within the organisation, sessions include: reliability, harm verses error,
driver diagrams, using data for improvement


5 Clinical Leads for Patient Safety have recently been appointed by the Chief Operating Officer as part of
the new organisational structure



                Improvement to tracker system made including
                e-mail reminders and realistic timescales for
                completion of actions
             Scottish Patient Safety Programme
            Medicines Management Driver Diagram
 Outcomes             Primary Drivers         Secondary Drivers
                        Processes, Rules of        Components, Activities
                        Conduct, Structure
                                              Use standardised protocols and algorithms
                                                 for high risk meds
                      Provide reliable        Routine and reliable patient and laboratory
Safe &                medicines                  monitoring
                                              Identify high risk areas using FMEA
effective             management              Pharmacy consultation service
                      processes               Identify patients at risk with high-alert
medicines                                        medications
management                                    Standardise recovery protocols (e.g.
(Reduce adverse                                  opiate over-sedation)
drug events: r/t
high risk processes                           Accuracy of medicines at the interface
& medicines e.g.      Coordination of         “One stop” delivery system
                      care                    Reliable in-hospital handoffs
medicines at the
                                              Communication with primary care
interface and
                                              High risk medicines management services
                      Patient and family      Patient and family education
                      involvement             Self management protocols
Medicines Reconciliation Perth Royal Infirmary - PDSA Cycle

                                Implementation of medicines reconciliation on all patients
                                admitted to Perth Royal Infirmary within 6 months

                                   Achieve 95% compliance with medicine reconciliation
                                   process on all patients
                                      Adapt and test existing medicines
                                      reconciliation form used at Ninewells

                                                     Med rec form now in all admission
                                                     packs and testing of data collection
                                                     continues. Data successfully collected
                                                     as part of ward round.

                                        Data gathered as testing continues to include all
                                        patients, and to support this process one consultant
                                        tested the inclusion of med rec as element of his ward
                     Testing continued no changes to form required however educational
                     issues identified and plans for educational sessions planned and
                     delivered by pharmacist to the medical staff

      Test the medicine reconciliation from implemented on the Ninewells site on one
      patient by one doctor supported by one pharmacist.
      Medicines Reconciliation Mental Health Services - PDSA Cycle
                               Implement Med Rec in Mental Health

                               95% compliance with Med Rec
                                                                      Implementation of
                               Adapt and test existing Med Rec
                               process from other areas, for use      Med Rec Process,
                               within Mental Health Wards             monthly
                                                                      monitoring of

                                                                   Test 4: Further Testing
                                                                   of Med Rec Process

                                             Test 3: Testing of Med Rec
                                    Test 2: Further testing across variety
Adapt Med Rec                       of conditions to ensure form fit for
 Form for use                       purpose. Format agreed for use.
within Mental
    Health              Test 1: Test suitability of
                        Med Rec Form
             KEYS TO SUCCESS


During early testing and implementation a medical champion was identified. This Consultant
supported the implementation by focusing on medicine reconciliation completion on every patient
during his daily ward round. Junior doctors are challenged if the form is not completed.

Changes were supported by a comprehensive education programme delivered by the ward
pharmacist. This was directed at medical staff and included the teaching of FY1 doctors on induction
highlighting the errors as a result of inaccurate reconciliation.

The pharmacist and medical staff have access to the Emergency Care Summary providing an
additional source of patient‟s medication history.

Measurement of medicine reconciliation compliance has been extended to include accuracy and this
information is reported every three months at the clinical effectiveness meetings
              KEYS TO SUCCESS

The patient safety framework across Tayside facilitates sharing of progress and challenges across
workstreams. The Pharmacist within the Acute Mental Health Ward at Murray Royal Hospital
recognised potential of testing the medicines reconciliation form already implemented in Perth Royal

Pharmacy resource within this service is limited and therefore it was vital that medical staff support
this change. General Adult Mental Health Consultants agreed to review and check the medicines
reconciliation forms at the ward round following admission. They also requested that the run chart
illustrating the data be displayed within the ward areas to facilitate improvement in compliance. They
also proposed that two junior doctors be selected for registration with the ECS.

Induction and teaching sessions have been delivered to new junior doctors. These sessions have
been delivered by Specialist Pharmacist and Consultant Psychiatrist

                          No data due to
      No data due to     staffing resource

     staffing resource



Their involvement is vital for spread, sustainability and aligning objectives to existing national targets.
SPSP changes are still seen as another initiative, therefore change is required to be integrated into
everyday practice and so becomes part of “the way we do things around here”


We have medicine management and everyone is responsible; it remains a challenge to ensure we do
not create a pharmacist dependant process.


Supporting frontline staff and managers to relate process and outcomes measures in their
improvement work.


Developing robust and comprehensive communication links enabling continuity of care 24/7
throughout the patients journey whilst improving patient safety.
      Help Needed Please!

   Involving patients more in each workstream
   Involving patients in walkrounds
   SPSP tool kit of resources
   Engaging GP and Out of Hours
   Implementing WHO checklist

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