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PHOTOGRAPH HERE
From Pen to Patient:Improving Prescription Writing Practice at a Psychiatric Teaching
Hospital
Dolores
Keating
MPSI
Head of
Pharmacy
WHY PRESCRIPTION WRITING?
Medication errors are one of the most common causes of patient harm1
Poor prescription writing is a factor
National and international patient safety issue
Baseline audits in Irish hospitals show low rates of adherence to good practice guidelines2-5
Quality improvement processes including audit and feedback, educational initiatives, improving medication charts and multidisciplinary working can raise standards3-7
Sustaining improvements is a challenge
1. NPS, UK, 2009 www.npsa.nhs.uk2. Farooq et al, It J Med Sci, 2008; 177; 243-2453. Ahmed a et al, Ir J Psych Med 2011; 28(2): 84-864. Tully et al, Ir J Psych Med 2010; 27(2): 82-85
5. Bates et al, Ir J Med Sci: 2010; 179: 183-1866. Dornan et al, EQUIP Study, 2009; www.gmc-uk.org7. Health Foundation, UK, 2012; www.health.org.uk
AUDIT CRITERIA• Allergy documentation
• Generic prescribing
• Handwriting: written in block capitals or un-joined lower case
• Start date
• Discontinuation process completed
• Patient name and MHIS number on each page (2012)
• Prescribers signature bank and MCRN completed (2012)
PRN Medications
• Dose specified
• Interval specified with maximum frequency in 24 hours
• Weekly review of PRN medications documented (2012)
SAMPLING
Every 4th name on an alphabetical list
25% of inpatient cohort over one week
N=40 to 50
Some standards may not apply to all charts e.g. if no PRN medication prescribed
STANDARD100% adherence within the entire chart with the criteria
Exceptions defined
• Brand name of a product that is not inter-changeable e.g. Priadel ®• ‘nocte’ for frequency of hypnotic in PRN section
INTERVENTIONSPre-audit •Introduction of a new medication charts
•Dissemination of Good Prescribing Practice Guidelines
Baseline2010
•Intensive targeted feedback
Re-audit 2010
•Good Prescribing Practice Education•Review of Medication Chart
Re-audit 2012
•Good Prescribing Practice Education Mandatory
Re-audit 2013 •Pilot targeted feedback for PRN review•Improved medicines reconciliation
Re-audit 2014 •Targeted feedback for Prescribers Signature and PRN standards•Format of Good Prescribing Practice Education Reviewed
Pharmacists screening medication charts
Reinforcement of Standards
Medication safety event reports analysed
Dissemination of Guidelines
Active and Passive Feedback
TARGETED FEEDBACK
TARGETED FEEDBACK
EDUCATION
REVIEW OF MEDICATION CHART
Draft HSE/State Claims Agency/Mental Health Commission Guidance for design & Governance of the Mental Health in-patient Medication Prescription & Administration Record (MPAR) 2012
National HSE MPAR Guidelines for Acute Hospitals 2012
Standards for the design of Hospital in-patient prescription charts UK: Academy of Medical Royal Colleges, Royal College of Nursing, Royal Pharmaceutical Society UK
National In-patient Medication Chart Standards, Australia
PROMPT TO CLARIFY TIME OF ADMINISTRATION
PROMPT FOR REWRITING CHART DURING NORMAL WORKING HOURS
LAYOUT OF PRN SECTION
LAYOUT OF PRN SECTION
SUPPLEMENTARY CHARTS
MEDICINES RECONCILIATION
Allergy documentation
RESULTS
Dose
Specif
ied
PRN
Frequ
ency
PRN
Indi
catio
n PRN
Revie
w PRN
Discon
tinua
tion
Gener
ic
Handw
ritin
g
Name
Every
Pag
e
Allerg
y
Sign
Bank a
nd M
CRN0
20
40
60
80
100
Baseline
Baseline
RESULTS
Dose
Specif
ied
PRN
Frequ
ency
PRN
Indi
catio
n PRN
Revie
w PRN
Discon
tinua
tion
Gener
ic
Handw
ritin
g
Name
Every
Pag
e
Allerg
y
Sign
Bank a
nd M
CRN0
102030405060708090
100
Baseline2014
RESULTS
Dose
Specif
ied
PRN
Frequ
ency
PRN
Indi
catio
n PRN
Revie
w PRN
Discon
tinua
tion
Gener
ic
Handw
ritin
g
Name
Every
Pag
e
Allerg
y
Sign
Bank a
nd M
CRN0
102030405060708090
100
Baseline2010201220132014
CHALLENGES
Labour intensive
Turnover of medical staff
Sustainability
Audit standard
Passive dissemination of guidelines and feedback
Different prescription charts and guidelines across the mental health services
WHAT WORKED?
Improve prescription charts
Prescription monitoring by pharmacists
Medicines reconciliation
Audit and active feedback
Education
Multidisciplinary working
Leadership
Support at governance level
Patient safety culture
WHERE TO NOW?
Medicines Management in Mental Health
Education
National Guidelines
Electronic Prescription Writing
THANK YOU
Aoife DavisAudrey PurcellLorna Dillon
Caroline HynesAoife CarolanCiara Dowling
De Abbie LaneDr Susan fletcher JonesDr Rory ShelleyDr Stephen McWilliamsDr Brendan Cassidy
Cathy ShelleyStephen BossBrid O’MearaRuairi Corkery