The Scottish Patient Safety Paediatric Programme

1. The Scottish Patient Safety Paediatric Programme NHS Borders

2. Where are you with respect to the paediatric programme medicines management process • We have begun by reviewing our Medicines Management processes in order to reduce errors in the administration of medicines 1st Steps Introduction of the safety measure for administration of medicines by: • Introducing a flowchart for the administration of drugs based on NMC standards for medicines management • Senior staff observe drug administration using a checklist based on NMC standards for medicines management • Raising awareness amongst all staff of the need for quiet during drug checking • Use of highlights to ensure all staff know when nurses are checking medicines eg red aprons; barrier belt • Data display

3. Existing local data • Drug error rates Sept 09-Sept 10 • Total number of errors: 39

4. Existing local data

5. Existing local data

6. Aim: To ensure that the flow chart is used correctly, during drug administration, 95% of the time by use of the PDSA ramping up tests 1-3-5 system, in Ward 15, by the end of October 2010 Plan DoDescribe what actually happened when you ran the test StudyDescribe the measured results and how they compared to the predictions ActDescribe what modifications to the plan will be made for the next cycle from what you learned

7. First Test of Change DATA FEEDBACK TO FRONTLINE STAFF: 1.Crash Call Rate 2. Percent Compliance w EWS 3. Percent compliance with EBAR 4. Percent of patients with appropriate interventions D S P A A P S D D S P A A P S D A P S D Change 4: Change 3: Change 2: Change 1: One observation of drug administration was made of two nurses in Ward 15 using an observation check list

8. PDSA CONTINUED What actually happened • Check list was available and used • Check list required some adaptation e.g. time of last dose not included • 7 Interruptions during procedure • Social chatter during procedure • Red aprons not available Actions Feedback todrug administrators following observations Will include run charts for No’s of interruptions No’s of drug errors No’s of checks complete Check list will be adapted to include time of last dose administered

9. Where we are with measurement and reporting • Continuing with observations using 1-3-5 test system • Numbers of interruptions are measurable • Number of completed checks measurable • Number of drug errors measurable • Ideas for change • Patient safety notice board in drug preparation room • Includes data related to drug errors over past 13 months • Feedback to drug administrators following observations • Will include run charts for numbers of interruptions / numbers of drug errors / numbers of checks complete

10. Paediatric Programme Goals - Focused Questions • Is this work making a difference? • Embraced by ward staff • Talking point for staff therefore raising awareness of problem • Interest in data and becoming involved • Should we be displaying days since last drug error? • Needs balance between ensuring incident reporting and managing risks • Currently > ….. days since last drug error