Nursing Unit Hospital Raja Permaisuri Bainun Ipoh

Introduction

Background & Problem Statement

Methodology

Result Discussion Recommendation Conclusion

Literature

Review

Presentation Outline

Introduction & BackgroundIntroduction

• 4 cycles of prospective clinical audit related to shift handoverprocedure and medication error study.

• Shift handover procedure is the outgoing nurses discuss with theoncoming nurses the condition of each patient and any changesthat have occurred to the patient during the shift (Groves et al2016).

• Defined by the National Coordinating Council for Medication ErrorReporting and prevention (2007), medication Error is

• ‘‘Any preventable event that may cause or lead to inappropriatemedication use or patient harm while the medication is in thecontrol of health care professional, patient, or consumer. ”

• The importance of nurses roles and responsibilities is to ensureMedication safety.

Problem statement

• The 13 Malaysian Patient Safety Goals (2015) no. 7 is to ensureMedication safety.

• Malaysian Nursing Division has initial National Nursing Audit as ayearly essential audit on oral medication procedure to sustain andreduce medication error since 2005.

• There were 8 incidences of medication error (nm/r) in HRPB whichinvolved nurses related to missed or ineffective communicationduring handover from 2015 to 2016.

• The nurses to nurse’s handover are not taught formally duringnursing training, yet it is one of the most important rituals of thenursing shift.

• We identified that the variation of SOP failed to communicate andcheck medication before serving to the patient as well as failed tocheck during shift handover procedure are the main weaknessescontributing to Medication Error after RCA.

Literature Review

• Joint Commission’s 2006 National Patient Safety Goal 2:Improve Staff Communication and Goal 3: Improve the Safetyof Using Medication emphasized that the importance ofcommunication between the healthcare staff to ensuremedication safety.

• Hansten(2003), the primary goal of shift handover is tocommunicate the patients’ clinical information and to providea safe and high-quality care.

• Lally (1999), evidence shows that effective shift handoverdecreases the risk of medication error and sentinel events,delays the course of treatment, decreases patient satisfaction,and prolongs the length of hospital stay.

Objective of study

• To Reduce the Incidence of Medication Error by Counter Checking the Medication Prescriptions and Medication-related Nursing Documentation by Nurses During the Procedure of Shift Handover

Specific Objective:

• To observe the compliance of medication prescriptionswere counter checked by nurses during the procedureof Shift Handover.

• To observe the compliance of all medication-relatednursing documentation been counter checked byNurses during shift handover.

• To observe the compliance of all prescribed medicationsas in medication chart been signed by Nurses as evidentafter served.

• To monitor and record the incidence of medicationerror prospectively.

Clinical Audit – Criteria & Standard

Criteria Standard

All medication prescription were counter

checked by Staff Nurses for Right

Prescription during the process of Shift

Handover.

100% of medication prescriptions werecounter checked by nurses during theprocedure of Shift Handover.

All medication-related nursing

documentation has been counter check

by Staff Nurses during the process of

Shift Handover.

85% medication-related nursing

documentation were counter checked by

Staff Nurses during the procedure of Shift

Handover.

All medications chart has been counter

check for the evidence of medications

been served (signature) by nurses.

100% medications chart were counterchecked for the evidence of medicationsbeen served (signature) by nurses.

Outcome

Number of Medication error recorded &

reported (prospectively)

Zero Medication Error related to invalid

prescription and failure to communicate.

Methodology

Over View & Study

Design

Part I is an observational clinical audit by using astandardized checklist to measure the compliance of nursesduring the procedure of shift handover.Part II is to monitor and record all medication errorprospectively

Location Medical/Surgical/Orthopedic / O&G wards

Population All Nurses in the selected wards

Sample and sampling 8 sections of shift handovers randomly selected from eachward (location) for each cycle

Auditors Repeated training require before each audit cycle

Period of audit 2 weeks

Inclusion Criteria Sections of shift handovers included 3 shifts AM/PM/ON

Exclusion Criteria none

Definition of Variables Variables Operational Definition

Medication Error

Any preventable event that may cause or lead to inappropriatemedication use or patient harm while the medication is in the control ofhealth care professional, patient, or consumer.

Shift Handover is a communication that occurs between two shifts of nurses wherebythe specific purpose is to communicate information about patients underthe care of nurses.Whereby the process of transferring primary authority and responsibilityfor providing clinical care to a patient from one departing caregiver to ononcoming caregiver.

Medication & Nursing care

related document

Documents include :Inpatient Medical Record, Medication chart, Nursing assessment chart,Nursing Care plan, Nurse Observation Chart and Intake output chart.

Inpatient Prescription

Chart

Chart for the prescriber to prescribe medication for the inpatient in theward. Nurses will send this char to the pharmacy department to indentthe required medication as prescribed.

Nurses Trained Registered Staff Nurses Grade U41 and U29/U32

Part 1 : Clinical Audit Checklist- Checklist NCA/HRPB/CL-01

S/N StatementMeasurement ( √ )

Yes No NA

1. Shift Handover on time

2. Handover and counter check patient condition bed to

bed between the staff of both shifts.

3. Did the staff communicate with the patient?

4.1 Handover and counter check current and update

contents of patient’s nursing documentation included:

Nursing Assessment – the patient’s condition should

coherence to prescribed medication.

4.2 Nursing care plan (NCP)

(Check related prescribed medications as intervention

according to patient’s condition)

4.3 Nursing reports related to the implementation of

intervention and evaluation (especially related to

prescribed medications) in NCP.

Part 1 : Clinical Audit Checklist- Checklist NCA/HRPB/CL-01 –cont’

S/N StatementMeasurement ( √ )

Yes No NA

5. Patients care associated charts:

5.1Temperature chart (may related to anti-pyrexia/antibiotic/side effect)

5.2 Vital sign (may be related to almost all drug and side effect)

5.3Pain Score assessment (may be related to before and after an analgesic)

5.4 Intake /Output chart (may related to diuretic or others)

6.Each prescription in medication chart is correctly prescribed as recorded accordingly in the patient’s clinical notes.

7.Each prescribed medications in drug chart were signed for served by SN.

8.Any un-signed column should be confronted by both shift’s RNs and reported to superior immediately.

9.Any query related to prescribed medications should be clarified between the 2 shift staff immediately

Ethical Considerations

• This study obtained approval from the Hospital Director and Chief Matron.

• Registered to National Medical Research Registry (NMRR) prior to conducting the study

– (NMRR-16-836-30770(IIR)

• And this project was approved by MREC to collect data from KKM setting- HRPB

• All the information enrolled by participants were kept confidential.

Data Processing And Analysis

• The collected data processed and analyzed bymeans of descriptive measures using the statisticalpackage for the social sciences (SPSS).

• The total and frequency (in percentage) method willbe used to analyze the result in part I and part II.

• The summarized data will be presented in form ofgraphics and tables accordingly.

Clinical Audit decision made as QIP of Nursing Unit HRPB

Training the auditors

Formation the Audit Committee

Project proposal agreed by Hospital Director and registered to NMRR

Topic and Area of Clinical Audit been identified

Group of Nurses

Checklist 1 Analysis by SPSS

descriptive

Reporting

Monitor & Record of Medication Error

Methodology Flow Chart

Gantt Chart of Project Clinical Audit 1st Cycle

S/NClinical Audit

Activities

Project weeks Apr to Jul 2016

April 16 May 16 Jun 16 Jul 16

1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th

1.Group Formation &

Choose topicX

2.

Agree/Review

Standards and

completed Proposal

for approval

X X X

3.Collect Data On

Current PracticeX X

4.

Analyses Data And

Compare Data With

Standards

X

5.

Discuss Finding &

Reliable Improvement

Action

X X

6.Planning For Agreed

Change /InterventionX

7.

Implementation

/Assisted &

Monitoring

X X X X X

8.Re-audit After 3

MonthsX

9. Report & Presentation X X

Summary of The Audit Cycle

Cycle Ward involved sample Period Improvement Set Standard

1st General Medical Ward only –(n=56)

May 2016 as proposal 100%of medication prescriptionsand nursing care related documentswere been counter checked bynurses during the procedure of ShiftHandover.

2nd General Medical / Surgical Wards -

(n=57)

Aug 2016 Amendment to the

Checklist

1.100% of medication prescriptionswere counter checked by nursesduring the procedure of ShiftHandover.2.85% medication-related nursingdocumentation were counterchecked by Nurses during theprocedure of Shift Handover.3. 100% medications chart werecounter checked for the evidentbeen served (signature) by nurses.4. Zero Medication Error related toinvalid prescription and failure tocommunicate.

3rd General Medical / surgical/orthopedic

Wards (n=104)

Aug 2017 Amendments to the

Checklist

4th General Medical/Surgical/Orthopedic /O&G

Ward (n=151)

Aug 2018 -

General Observation Result

Part 1: Observation clinical audit

S/N StatementAchievement /compliance %

1st cyclen=56

2nd cyclen=57

3rd cyclen= 104

4th cyclen=151

1. Shift Handover on time 98 100 98 100

2. Shift Handover process

bed to bed 75 98 98 98.7

3. Nurses communicated

with patients- - 60.2 66.2

At the 4th cycle, 100% of shift handover happen on time between the two shift with 98.7% were occur bed to bed.However, there was only 66.2% of nurses communicated with patients.

Standard 1 = 100% of medication prescriptions were counter checked Standard 2 = 85% of medication-related nursing documentation were counter checked Standard 3 = 100% medications chart were counter checked for the evidence of

medications been served

64.3%67.3%

84.5%90.1%

43.9%

64.3%

74.9%

87.0%

89.3%95.2% 95.2% 95.4%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1st Cycle 2nd Cycle 3rd Cycle 4th Cyele

Compliances to Standard

Standard 1

Standard 2

Standard 3

Part I Audit Result

16.1%

10.5%

15.7% 14.6%

32.1%33.5%

31.0%29.5%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

1st Cycle 2nd Cycle 3rd Cycle 4th Cycle

Clarification when any ambiguity or unsigned

Unsigned Column Ambiguity

There is an average about 14.2% of the unsigned column and 31.5% of the ambiguity were been clarified during the shirt handover report shown in all the 4 audit cycles.

Compliance to Standard 4 Zero Incidence of medication error

From Jul 2016 until 31 Aug 2018. There is Zero Medication Error reported in HRPB related to medication prescriptions or missed communication during shift handover .

Part II Audit Result

Discussion

• Awareness to all nurses counter checking is essential during each shift handover

• Amendments of the audit checklist and training for all staff including auditors as required.

• Better communication with other profession such as Medical Officer and pharmacist could reduce ambiguity.

• Communication between nurses with patients is another important issue need to be improved as included in 3rd & 4th cycles of audit.

Action plan

Recommendation Action RequiredPossible barriers

to implementation

Responsible person

Timescale

Standardized of the process and content of Shift

Handover in Basic Nursing Training program

Higher Nursing Authority/

Nursing Institution

Syllabus added/ require extra credit hours

Top Management

-

Enhance communication between patient and staff in

the wards

Nursing Management

knowledgeattitude

Skill PJ & KJ

6-12 months

Extend the clinical audit to all the wards as yearly event

prospectively

Nursing Management

knowledgeattitude

Skill PJ & KJ

6-12 months

Fine improvement on the Checklists are required for

better understanding

Audit leader & team

knowledgeExperience

Skill Audit team

2-4 weeks

Retrain and recruit new auditors are essential

Audit leader & team

knowledgeExperience

SkillAudit team

3-6 months

Conclusion

• The compliance to standard of clinical nursing audit shown:

• Effective shift handover with proper counter checking themedication prescriptions and medication-related nursingdocumentation by nurses has significantly decreased the riskof medication error and sustained medication safety as theresult shown zero incidence of medication error afterimplementation of the project.

• However further knowledge development of the handoverprocedure is required for betterment.

Acknowledgement

Grateful to the Hospital Director and the Chief Matron and Matron Committee of HRPB who’s been generous and supportive for me to complete this study.

Appreciation is given to Nursing Sisters and all nurses who involved in the Clinical Audit for their kind attention, commitment and participation.

A big thank you to our patients who committed to our audit and nursing care.

References

• Groves, P. S., Manges, K. A., & Scott-Cawiezell, J. (2016). Clinical Nursing Research. Handing Off Safety at the Bedside .

• Hansten, R. (2003). Notes from the field. Streamline change-of-shift report. Nursing Management. Aug; 34 (8): 58-59.

• Lally, S. (1999). An investigation into the functions of nurses’ communication at the inter-shift handover. Journal of Nursing Management, 7, 29-36.

• National Coordinating Council for Medication Error Reporting and prevention (2007)

• The Joint Commission’s 2006 National Patient Safety Goal• The 13 Malaysian Patient Safety Goals (2015) Nursing Division• World Health Organization (2007). Communication during patient

hand-overs. Patient Safety Solutions, 1(3). Accessed from http//www.who.int/patientsafety (26 May, 2008).