Introduction Situation Awareness For Everyone (S.A.F.E)1 is a two year programme led by the Royal College of Paediatrics and Child Health in partnership with NHS hospitals, to aid the development of a range of quality improvement techniques with the aim of reducing preventable deaths and errors occurring in the UK’s paediatric departments.
The neonatal unit began daily safety huddles to identify ward risks and share learning points in September 2015. An NHS Trust piloted the ‘druggle’, a ‘ward-based safety huddle’ with ward pharmacist, doctors and nurses, as part of the S.A.F.E project, on their neonatal ward in July 2015.
Aim The aims of the druggles are to increase communication between pharmacists, the medical team and nursing staff, and to educate all staff regarding specific drug related topics. They enable the team to receive feedback on anonymised errors in real time, draw attention to areas for improvement, encourage discussion and share learning points from them.
Method The druggles were developed as drug related safety briefings. They are presented once a week as part of the daily huddle. The basic format of the sessions is a weekly ‘hot topic’, for example recent BNFc changes, an ‘error of the week’ and celebration of good prescribing practice. Themes are identified by members of staff and discussed at the druggles as they arise. This enables timely education and discussion of topics as they occur.
The neonatal pharmacy team completed a baseline prescribing standards audit in February 2016 (after the induction of the new medical team) which will be repeated before the doctors rotate in August. This audit provided information about common prescribing errors and helped to identify possible ‘hot topics’ for discussion. A ‘zero tolerance’ audit of 5 randomly chosen prescription charts is completed weekly to assess prescribing standards in real time. A chart ‘fails’ when the first prescribing error, or deviation from prescribing standards, is picked up.
Results The baseline audit of all charts on the unit showed poor compliance with prescribing standards overall, particularly when transcribing or cancelling prescriptions. Subsequent weekly ‘zero tolerance’ audits have shown an improvement from 20% of prescription charts with no prescribing error to 65% with no errors over the first 12 weeks.
Conclusion An improvement of prescribing standards has been observed from the initial findings of the ‘zero tolerance’ audit. The druggles have encouraged more discussions, allowed the MDT to work together to improve the standards of prescribing and have proved to be an invaluable tool when implementing new processes. Developments have also been made to existing processes, such as the separation of babies’ drug charts from their mothers’ charts on the postnatal ward as a result of an error discussed at a druggle. The druggles have now begun to be implemented throughout the Children’s Hospital.
Royal College of Paediatrics and Child Health. Situation awareness for everyone (S.A.F.E.) programme2016. http://www.rcpch.ac.uk/safe [Accessed: 6 July 2016].
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