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