Context This ongoing work is being done in the busy General Paediatric Department of our Hospital. It involves doctors of all grades who prescribe medication for paediatric medical inpatients.
Problem A high incidence of errors and omissions identified in audit of prescription charts, despite paediatric prescribing being discussed at every junior doctor induction programme, led to initiation of this project.
Assessment of problem and analysis of its causes The problem had already been quantified by previous audits. Doing a weekly prescribing review by randomly selecting 2 drug charts from each of the 3 wards and discussing them as a team helped identify key issues. This led to all staff being actively involved from the early stages. Various interventions were introduced as follows.
Intervention Interventions were escalated to achieve the desired outcome, with weekly performance monitoring by review of randomly selected drug charts.
Cycle 1: Review of drug charts to identify problems
Cycle 2: “Prescribing lesson of the week” posters in the doctors' office
Cycle 3: Personal emails with recommendations to individuals who had made errors or omissions
Cycle 4: Combining personal emails with a themed, eye-catching poster
Cycle 5: Introducing star chart to positively motivate good performance, continuing personal emails
Cycle 6 (December 2014): Increasing sample size- all charts from one ward
Cycle 7 (January 2015): increasing sample size- all Paediatric Wards
Cycle 8 (March 2015): Re-audit
Study design This project is designed as per the Plan-Do-Study-Act Cycle suggested by the Institute for Healthcare Improvement's Model for Improvement: small sample cycles were performed to identify the main prescribing problems, implement changes and test the effect of each intervention.
When improvement has been maintained in the small sample cycle we plan to expand the study sample (December 2014) and demonstrate the overall impact and change (if any) in the Department.
The goal is 100% BNFC general guidance compliant drug charts by the end of January 2015 for all medical paediatric patients.
At the final stage of the project (January 2015) measures aiming to preserve the improvement overtime will be introduced and will be tested after the trainees rotate (March 2015).
Strategy for change Interventions were escalated and implemented as described. All staff were active participants at every stage and consequently were aware of planned interventions.
Measurement of improvement The percentage of BNFC general guidance compliant drug charts out of the total number of drug charts reviewed per cycle has been set as a quantitative outcome measure to compare results and quantify progress.
Effects of changes Fewer prescription errors and omissions were noted following the implementation of intervention with inferred improvement in patient care.
Lessons learnt Sustained team focus and escalating interventions tested in rapid cycles led to the desired outcome becoming achievable. Staff involvement early in the choice of intervention may have shortened the time to achievement of goal and reduced resistance.
Message for others A clinical improvement project with short, small sample PDSA cycles and early staff involvement leads to quicker and possibly more sustained benefit. Positive identification of individual good practice motivates improvement.
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