Context This project was undertaken in a Paediatric Intensive Care Unit (PICU). The staff groups involved were prescribers.
Problem This study concerns quality of documentation of antibiotic prescriptions. Poor documentation on paper charts can lead to a range of medication errors, including incorrect timing of review.
Assessment of problem and analysis of its causes Standard of documentation was quantified by measuring the prevalence of correct documentation of 11 quality indicators. A prevalence study of this depth had not been carried out previously in this setting.
Intervention There were 2 interventions in this study:
Excellence reporting (ER): ER is appreciation of excellent performance through a formal system of reporting. ER is a peer-reporting system for capturing excellence in any aspect of work, and has been established in our institution for 18 months. ERs are electronic forms, with free-text description of the episode of excellence. Reported individuals receive a copy of the excellence report. In this study, all prescribers who achieved success in 11/11 quality indicators received an ER.
Anonymous photographs of “gold standard” prescriptions were displayed in prescribing areas in PICU.
Study design This was a prospective, observational research study. The prevalence of quality indicators of antimicrobial prescribing was measured at 2 time-points pre-intervention and post-intervention. Each drug chart on PICU was included. The 11 quality indicators were: allergy status; patient name, date of birth and hospital number; weight; start date; route; generic drug name; legibility and black text; indication; review date; prescriber name, signature and GMC number; correct dose and units. “Gold-standard” was defined as presence of all 11 quality indicators. A single researcher carried out all observations, over a study period of 1 month.
Strategy for change The change in this case was positive feedback via excellence reporting. This was carried out using an existing system for ER (Learning from Excellence). All reports were completed by the study team.
Measurement of improvement There were 55 prescriptions pre-intervention and 54 prescriptions post-intervention.
Main finding gold-standard prescriptions accounted for 18.2% of all prescriptions pre-intervention and 35.2% of all prescriptions post-intervention (p = 0.045).
There was a significant improvement in both allergy status and prescriber details documentation post-intervention: allergy status was recorded in 78.18% pre-intervention and 92.59% post-intervention drug charts (p = 0.034) and prescriber details was recorded in 65.45% pre-intervention and 94.44% post-intervention drug charts (p = 0.00016). There was also improvement in legibility and treatment indication record, both of which improved by 16.33% (p = 0.0047). The quality indictor not documented, most frequently, was antibiotic review date without significant improvement post intervention (p = 0.29).
Effects of changes In this proof of concept pilot study, we have demonstrated the effect of excellence reporting in improving performance in a discrete area of clinical practice.
No difficulties were encountered during the intervention, other than the time required to complete the forms (approximately 1 min per report).
Lessons learnt This was a pilot study; the next steps are to test if this approach is sustainable, and if it is applicable to other areas in our practice. Reducing barriers to reporting (e.g. by allowing mobile telephone reporting) has been introduced to increase access to this initiative.
Message for others Quality Improvement (QI) and safety initiatives in healthcare have tended to focus on identifying errors or harm, and introducing changes to reduce error or mitigate risk. This approach is valid, but may miss opportunities to learn from and replicate excellent practice. Our study has shown (within the limitations of a small pilot) that performance of healthcare staff can be increased by showing recognition and appreciation of excellent practice, and we suggest that this approach could be adopted more widely, to complement existing QI initiatives.
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