chance to check
DESCRIPTION
Chance to Check. Karon Cormack Clinical Risk Manager Greater Glasgow & Clyde Health Board. Medication incidents. Interested in wrong patient incidents Violation of policy Theory regarding the reasons SPSP work – deliberate design vs hard work and vigilance Chance to check concept. - PowerPoint PPT PresentationTRANSCRIPT
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Chance to Check
Karon Cormack Clinical Risk ManagerGreater Glasgow & Clyde Health Board
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Medication incidents
Interested in wrong patient incidents Violation of policy Theory regarding the reasons SPSP work – deliberate design vs hard
work and vigilance Chance to check concept
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Focus Groups
Medication errors and practice:
5 groups between 6 – 24 (12 ideal) Hardly any had been involved in a focus
group before Wary at first but soon talked freely Debated with each other Needed to be controlled without influencing Rich source of information
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Focus Groups - medication round
Not enough time Debate about who should do it Lost importance Feels very task driven Underlying concern
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Focus Groups – current practice
Admitted to not checking name band Admitted giving drug they are not
sure of Admitted not thinking about the
patient in relation to the drug Admitted problems with no
interruptions
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Focus Groups – name band
Feel they know the patient Embarrassment - as if nurse has
forgotten who the patient is Don’t want to disturb patient e.g. at
night Time Felt to be different from blood
transfusion
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Chance to Check - content
Identifying 4 key statements that must be self asked on each administration
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I know what this drug is
I think this when I am dispensing the drug into the medicine cup.
Chance to Check 1.
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Chance to Check 2.
This drug and dose is suitable for this patient
I think this when I have dispensed the medication and I am thinking of the patient I plan to give it to.
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Chance to Check 3.
The patient verbally confirms their name if possible
On approach to the patient I ask for confirmation of name.
“Hi Mr Brown, I have your medicines, tell me your full name please”
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Chance to Check 4.
The patient's name band matches the kardex
I check the patient’s name band with the name and DOB or CHI number on the kardex.
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Chance to Check - content
Identifying 4 key statements that must be self asked on each administration
Prompt cards can be used initially but should become automatic.
Every patient, every time deliberate design.
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Chance to Check – time / focus
Take the time to get the task right Do the right checks Acts like a pause in the process Raise awareness of medication issues Prompt ward discussion Standardising approach
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Additional Points – No interruptions
Signage On admission Communication book Agreement on acceptable
interruptions Be strong and united
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Additional Points - BNF
One on each trolley Up to date Labelled
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Post Round Sweep
Reduce errors relating to medicines; Omitted / forgotten / lost Taken late Taken by other patients
Your drug round – your responsibility.
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Promote ward discussion
When & Who? Incidents feedback Review Chance to Check Praise
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Implementation
Pilot wards Spread to other wards in S&A Taken to Heads of Nursing and spread
to other directorates Included in MyMeds project Recently introduced to 3rd year
undergraduates
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Results
Staff like it Feel they have permission to do the
right thing Feel they are using nursing
knowledge Feel more assured the process is
good Less interruptions
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Any Questions?