Aim To demonstrate that administration of medicines, or omissions, are recorded clearly and accurately on paediatric inpatient prescription charts, in accordance with the Trust medicines management policy. To provide evidence to support adherence to the NHS Litigation Authority (NHSLA) standards and compliance with the National Patient Safety Agency (NPSA) rapid response report 009 actions.
Method The Trust requires healthcare professionals responsible for administering medicines to make a clear, accurate and immediate record of all medicines administered. The record must show a signature, date and time. Any reason for omission must be recorded using the appropriate code (as indicated within the prescription chart). 100% compliance is expected. A pharmacist/pharmacy technician collected data from each patient's current prescription chart(s) on the paediatric ward on one day. For each patient's chart the following were recorded:
Number of regular medicines (current and cancelled).
Number of doses of regular medicines (current and cancelled) that should have been administered since the start of the prescription chart, if all the prescribed doses had been administered as intended.
Number of pertinent administration boxes with no signature/no approved code (e.g. empty boxes, ticks).
Number of administration boxes containing an approved code.
Prescriptions for oxygen, parenteral fluids, nutritional feeds, stockings and dressings were excluded. This is a rolling audit carried out twice a year initially and annually thereafter. Feedback from the audit is presented at departmental meetings, ward meetings or clinical governance meetings. Following the NPSA rapid response report, a list of critical medicines was compiled and disseminated to staff in December 2011. The audit carried out after this time took account of the number of missed doses of critical medicines.
Results June 2010–150 doses (24%) missed out of 618 doses due, including 129 doses (21%) with no record of administration.
February 2011–30 doses (27%) missed out of 113 doses due, including 24 doses (21%) with no record of administration
October 2011–33 doses (12%) missed out of 279 doses due, including 28 doses (10%) with no record of administration.
April 2012–7 doses (15%) missed out of 47 doses due, including 5 doses (11%) with no record of administration, and 6 out of the 7 doses missed (13%) were for critical medicines.
Conclusion The standard of 100% compliance was not met at any of the times the audit took place. There was a 50% reduction in incomplete records of administration. There remains a need to reduce these gaps in patient records further. There needs to be better awareness that the prescription chart is part of the patient records and is thus a legal document that should be completed accurately.