Please Reconcile Not Wait a While!
We describe a quality improvement project to increase the rate of paediatric medicines reconciliation on a 25 bed paediatric ward.
In 2016 NICE published standards stating that inpatients in an acute setting should have a reconciled list of their medicines within 24 hours of admission. Evidence shows that medicines-related patient safety incidents are more likely when medicines reconciliation happens more than 24 hours after a person is admitted to an acute setting.
The initial idea for the project came after an incident at the weekend where both a post liver transplant patient and an oncology patient were not correctly prescribed their regular medications, including tacrolimus and long term prednisolone.
The number of regular medications and the number of medicines reconciled was recorded each day. Baseline data collected from our paediatric ward showed that medicines reconciliation by doctors was only completed 50% of the time.
Causes of the Problem
At our Trust, the medicines reconciliation policy states that the medicines reconciliation process should be initiated by the doctor admitting the patient and be supported by pharmacists and other members of the pharmacy team. Collection of the medication history should be from a variety of sources and usually this should be from a minimum of two.
Currently practice is that pharmacists are only present on the paediatric ward Monday to Friday during normal working hours. Therefore any patients admitted out of hours may not see a pharmacist for up to 48 hours. Evidence shows that medicines-related patient safety incidents are more likely when medicines reconciliation happens more than 24 hours after a person is admitted to an acute setting.
Project Aim Statement
The aim of this quality improvement project was to ensure that 100% of paediatric patients have their regular medications prescribed by midday the day after admission. Our baseline data showed that medicines reconciliation by doctors was only completed 50% of the time.
The project team consisted of the paediatric pharmacy team who were responsible for collecting the data and a lead paediatric consultant. At the start of the project we talked to doctors, nurses, children and their parents on the ward to ask them what medicines reconciliation meant to them.
We ensured that the paediatric team were aware of the project and shared the results in the WhatsApp doctors group and governance meeting. We also ensured that we regularly spoke to the nursing staff to address any concerns they might have. Parents reported they were really happy to be involved with helping to reconcile their children’s medications.
PDSA Cycles / Solution(s) Tested
After collecting baseline data we brainstormed ideas for change using the Plan Do Study Act (PDSA) method:
PDSA cycle 1: Paediatric teaching session discussing common prescribing errors, what medicines reconciliation means, why it is important and how to do it.
PDSA cycle 2: Posters displayed on the ward about medicines reconciliation.
PDSA cycle 3: Questionnaire given to children/parents given when they are admitted to the ward asking them about any medications they usually take.
PDSA cycle 4: Attendance at the paediatric governance meeting to update all staff about the project and the interventions so far.
PDSA cycle 5: A&E teaching session discussing prescribing for paediatric patients, what medicines reconciliation means, why it is important and how to do it.
PDSA cycle 6: Questionnaire given to children/parents in paediatric A&E asking them about any medications they usually take.
The paediatric pharmacy team reviewed all paediatric inpatient drug charts from Monday to Friday. The number of regular medications and the number of medicines reconciled was recorded each day. The effectiveness of various interventions were reviewed using PDSA cycles.
The mean reconciliation rate was 79%. 100% reconciliation was achieved on 34 occasions and was achieved continuously for the last three weeks of data collection.
The intervention with the most success was introducing the questionnaire. After PDSA cycle 6 we were able to maintain 100% medicines reconciliation. We hope this will help reduce harm to our paediatric patients from incomplete reconciliation.
How This Improvement Will Be Sustained
With rotating medical and nursing staff, consistent engagement is necessary in order to maintain this level of work. We ensured that we included all members of staff throughout the project and ensured we recognised their contribution to the success of the project.
A repeat audit was carried out for one week in September 2018 to see if this change had been sustained. We are pleased to report that for the duration of the data collection the reconciliation rate was 100%.
In order to continue to sustain this improvement we will need to ensure the paediatric pharmacy team continually engage both staff and parents in this project.
Challenges and Learnings
Training all members of staff to use the questionnaires proved difficult as we realised some members of staff, particularly nursing staff, only worked at night when we were not available. We relied on other members of staff telling them about our interventions.
Asking nursing staff to give out the questionnaires also meant extra work for them but we did not receive any negative feedback about this.
The main message we have taken from this quality improvement project is that you need to understand your problem before you try and “fix” it. In addition the real success of a quality improvement project is if you are able to sustain a change.
When trying to make changes to a process it is important to understand it before trying to implement any change. Additionally, small changes can often have a bigger impact than you first think.
Engaging all relevant stakeholders is really important – it was a pleasure to involve children and their parents in the discussions as they felt empowered and involved.
Suggestions for Further Implementation
Our initial data collection period was 12 weeks followed by a repeat audit two months later. The data collection period could be extended or further repeat audits could be undertaken periodically. This would help to continually engage all stakeholders.
This project worked in a multi-disciplinary environment like a paediatric ward. If the project was to be replicated in other areas it would need a strong multi-disciplinary team to ensure its success.
Project Lead: Ashifa Trivedi
Organisation: The Hillingdon Hospital