Moving Closer to the Bedside

Improving medication administration for children in hospital

Rachael WorthingtonThe Children’s Hospital at Westmead

Medication…and Errors

• Medication-related errors are a significant proportion of the preventable errors that occur in healthcare

• Children are particularly at risk

Weight-based

dosing?Age-based dosing?

Ability to

Communicate Range of dose forms

Medication Errors in Children…

Miller et al Qual Saf Health care 2007;16:116-126

The prescribing, dispensing and administration of medications represent a substantial portion of the preventable medical errors that occur with children…

5-27% of medication orders for children contain an error somewhere along the spectrum of the entire medication management process…

49%

14%20%

Quality in Australian Health Care studyMed J Aust 2005; 182 (6): 260-261.

At CHW• Most reported cause of

incidents at CHW• 2008-2011 yielded over

2300 incident reports – 3260 separate incident

types– 189 medications

• Average 45 incident reports per month

• Plus 35 pharmacy interventions per month

Administration of Medications• Checking

process often cited as ‘rushed’, ‘incomplete’ ‘interrupted’ ‘distracted’

• Workflow and time issues

A Family Affair…• Promoting self or carer-

administration of medications• Transcription or charting errors on

admission → Administration errors or delays → Family frustrated, disempowered.

A Family Centred approach decreases anxiety, increases compliance with what is required, which in turn improves outcomes, patient and staff satisfaction..

…and recognises that every family is

unique

Aims• To evaluate to impact of using an in-

room locked medication cabinet in a paediatric isolation/oncology ward– To improve compliance with current

medication administration policy– To increase carer involvement – To minimise medication wastage

Variety Ward• Our patients

– Oncology– Bone marrow

transplantation– Solid organ

transplantation– Chronic liver disease– Chronic renal disease– Rheumatology– Gastroenterology

• Project TeamNursing Unit Manager

Clinical Nurse Educator

Service Improvement Staff

Pharmacists

Nursing Staff

Pre-evaluation undertaken with

stakeholders

The Cabinet• Purpose built, wall

mounted, lockable box designed by the project team in consultation with the manufacturer

• Opens flat to create a work-surface

• Staff Focus Groups

Assessment Methods• Direct observation of

medication administration process

• Acceptability through staff and parent surveys

• Nurses experiences documented and discussed

Incident data• Increased incident reporting

– 23 between Mar-Aug 2011 vs. 36 between Sept 2011-Feb12

– No change in severity– Improvement in safety culture?

Effect on Workflow• Fewer distractions:

0.83 vs 1.21• Decreased administration time:

4.9 minutes vs. 5.84 minutes– Based on an average 196 medication

episodes per day = 184.24 minutes per day or 47 days per year!

What did staff think?POSITIVES NEGATIVES

- Being watched by parents

- Finding the second checker

- Stock maintenance- Noise and lighting at

night

Easier to

complete

check

More focused

Less distractionsReduces

spread of

infection

Close to patient

What did parents think?Pre-trial

• Overwhelmingly in favour of having medications prepared closer to child

• 85% would like to continue giving in hospital Safer Keeping the routine the same Don’t have to wait for nurses – they get very busy Easier Less distressing for the child

• Primary reason for saying no was wanting a break

More from the parentsPost-trial

Nurses can talk though the medications

Quicker, saves

time, less

interruptions

It’s visible to the child and it’s not scary; keeps the child happy

Parents feel

involved

Night activity was not seen as an issue – many parents slept through or felt the interruption took less time with everything already in the room

Parent EducationCase Study – “Henri” • 2 y.o. boy from New

Caledonia• French speaking mum

“Etienne”• Hx of JMML, BMT June

2011• Rocky course post

transplant

Henri’s Medication List – 1/2/12• Domperidone 3mg TDS via NG• Bactrim 30mg BD via NG• Ondansetron 3mg TDS via NG• Diazepam 2.5mg BD via NG• Lamotrigine 75mg BD via NG• Topiramate 40mg BD via NG• Aciclovir 150mg BD via NG• Nystatin 1mL QID swabbed

around mouth• Cholestyramine 5% paste topical• Clonidine 25mcg nocte IV • Levetiracetam 300mg BD IV• Phenytoin 35mg BD IV• Omeprazole 15mg BD IV

Medication List

Page 1 of 3!

Nurses would introduce medication as it was changed to from IV to oral.

Mum would add notes to chart for herself

Sustaining change• Policy around admission, administration and

discharge processes using the box.• Evaluation of parent/carers ability to

administer medications. • Ongoing education, information, support and

feedback via ward orientation processes.• Ongoing monitoring of IIMS, observations,

feedback from families.• Costing of medications on admission and

discharge medications, looking at the potential to use patients own medications to further streamline the medication administration process.

Preliminary Costings• 51 patients• Average number of regular

medications• New medications in 42%• 10% started on chronic

medication• Some patients transferred• Average cost saving = $125.45

Conclusion• Having medications in the room has improved

workflow, compliance with policy and showed benefits in terms of parent education.

• Well accepted by staff and parents.• Two systems in ward – difficult to maintain -

more boxes/more data.• Improvements to the system required: locking

system, drug information• COWs and medical carts being considered as

next phase.

With thanks…• Sonya, Lorraine,

Bronwyn and the Variety Ward Nursing Team

• Katrina, Peter, Demiana, Lucy and the CHW Pharmacy Department

• The CHW Service Improvement Unit