The work described here was presented at the Pharmacy Together 2019 conference.
On admission to hospital, patient’s medication care is usually withdrawn, regardless of capability, and instead nurses administer medication. The Royal Free London is one of the UK’s largest Trusts where currently there is a self-administration scheme which is only employed at a patient’s request. This quality improvement project aimed to improve the scheme on the cardiac ward to empower patients, enforce better counselling and resolve medication issues before discharge.
Most eligible patients would prefer to self-administer their medication in hospital. It also has the added advantage that self-administration increases their understanding of the medication. Patients should be counselled on prescription changes in real-time, yet this rarely occurs due to time constraints and on discharge they are expected to manage their medication at home.
During this improvement study, feedback was obtained from patients and staff continuously. Incident forms relating to medication administration were analysed, and run charts were created to identify trends in process measures over time.
In the first week of the intervention, all patients were assessed to self-administer. Whilst this increased awareness of the project, it also increased nursing workload so was subsequently revised.
During weeks two to four, the original assessment form was updated to be shorter and more succinct. In weeks five to nine, a self-administration drug chart sticker was created which improved awareness and streamlined the scheme. In the final three weeks, a ward-based dispensing service was introduced, where pharmacists could dispense medication and counsel patients promptly.
Patients felt empowered to continue taking ownership of their medication
The project team included pharmacists, nurses and doctors who met on a weekly basis. Data was collected over 12 weeks. Any member of the multi-disciplinary team could identify a suitable patient to self-administer using the assessment form. Nurses confirmed each medication administration and endorsed ‘self’ on the drug chart.
Process measures were the number of patients self-administering per week and the nursing time saved per drug round and per day. 32 patients self-administered during the PDSA cycles. Nurses saved around 10 minutes per patient per drug round and 33 minutes per day. We also found that self-administration prevented missed doses and delays in drug administration.
There were no complaints or incidents disclosed suggestive of communication failures. Although formal data was not collected, the Trust saved over £1000 from just one patient who brought in her ‘high cost drugs’ when readmitted.
Around two-thirds (n=20) of patients felt they knew as much about their medication as they did pre-admission, and around one-third (n=11) knew more due to more counselling. One patient was more confused because her nurse administered her controlled drugs.
This project demonstrated savings in nursing administration time, allowing them time for other tasks. In addition, patients felt empowered to continue taking ownership of their medication. Unanticipated consequences were saved dispensing time and costs. The multidisciplinary team pro-actively asked patients’ families to bring in medication from home which reduced medication wastage.
The next PDSA cycle is to implement key-free lockers with PIN codes known only by the patient and nurse.
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Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.