Drug administration errors in anaesthesia and beyondBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5823 (Published 22 September 2011) Cite this as: BMJ 2011;343:d5823
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Dear Sir/ Madam,
We note with great interest that, following on from the Welsh example, England is looking at implementing a universal Inpatient Medicines Administration Card. (The Academy of Medical Royal Colleges. Standards for the design of hospital in-patient prescription charts, April 2011 ) We agree with the principle that universality may decrease the scope for errors because all practitioners would be familiar with the documentation where ever they worked. Further, we had data which suggests that the optimal clarity that this document could encourage would also reduce errors. Clarity can be enhanced through improved legibility, reduced congestion (ie remove the unnecessary), giving more space for people to sign for prescribing and administering drugs, better colour contrasts and also giving thought to fluidity of movement of the practitioner using the document.
Over the last 3 years we have put together a team within our Hospital (Mersey Care NHS Trust) to look not only at this specific issue but also at all of the workflow, environment and equipment design involved in the process of medicines prescribing, dispensing and administration. Our methodology involves canvasing widely for ideas, investigating how systems can be improved, piloting these and then implementing the changes that are demonstated as worthwhile. As a mental health trust, this has allowed us to improve our processes in the absence of any appropriate electronic prescribing systems being available.
Although several arms of this work are ongoing, the modifications to our Medicines Administration Cards has been the most thorough to date. The most notable changes have been the implementation of "passport application" style boxes for handwriting the patient name and demographic details and also the drug names. This alone has reduced the rate of Illegibility down from 11% to Zero. Across our Hospital this equates to approximately 22,000 prescribed items that are no longer considered as potential errors. We have also made other improvements which seem to have reduced omissions significantly.
We have found however, that universality, even within our Trust, was difficult to achieve. We presently have two versions in use (for shorter and longer stay wards), with the likelihood that there will be another two versions developed. Whilst they will all initially look very similar, closer inspection shows that each is designed for a specific workplace.
Hence, we feel that while universality could be achieved nationally, it might be worth thinking about the possibilities of allowing each hospital to customise their own cards from a menu of options. For example, ours is a large mental health trust, and hence, we have no need for IV injection or fluids sections. However, we have found sections designed for depot injections quite useful. We have also found that a section specifically designed for staff to carry out rudementry physical observations (eg BP, pulse, BMs and weight etc) has been very successful. However, this wouldn't suit a medical or surgical unit because their physical observations are far more detailed and would require a more specific tool. Eliminating parts of a form that are not useful, and therefore often not completed, improves total completion, so important data is less likely to be omitted.
While many of these issues outlined above could be also dealt with via the use of EPMA (electronic prescribing and medicines administration) systems, this is still some way off for many organisations. Indeed, we feel that this process has allowed us to position our hospital very well for the arrival of such a tool, as we know what we want.
Dr Clare Brabbins Dave Kitchen
Consultant Psychiatrist Education and training Pharmacist
Mersey Care NHS Trust Mersey Care NHS Trust
Liverpool, L13 4AW
Competing interests: No competing interests