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Chance to Check

Chance to Check. Karon Cormack Clinical Risk Manager Greater Glasgow & Clyde Health Board. Medication incidents. Interested in wrong patient incidents Violation of policy Theory regarding the reasons SPSP work – deliberate design vs hard work and vigilance Chance to check concept.

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Chance to Check

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  1. Chance to Check Karon Cormack Clinical Risk Manager Greater Glasgow & Clyde Health Board

  2. Medication incidents • Interested in wrong patient incidents • Violation of policy • Theory regarding the reasons • SPSP work – deliberate design vs hard work and vigilance • Chance to check concept

  3. Focus Groups Medication errors and practice: • 5 groups between 6 – 24 (12 ideal) • Hardly any had been involved in a focus group before • Wary at first but soon talked freely • Debated with each other • Needed to be controlled without influencing • Rich source of information

  4. Focus Groups - medication round • Not enough time • Debate about who should do it • Lost importance • Feels very task driven • Underlying concern

  5. Focus Groups – current practice • Admitted to not checking name band • Admitted giving drug they are not sure of • Admitted not thinking about the patient in relation to the drug • Admitted problems with no interruptions

  6. Focus Groups – name band • Feel they know the patient • Embarrassment - as if nurse has forgotten who the patient is • Don’t want to disturb patient e.g. at night • Time • Felt to be different from blood transfusion

  7. Chance to Check - content • Identifying 4 key statements that must be self asked on each administration

  8. Chance to Check 1.

  9. Chance to Check 2.

  10. Chance to Check 3.

  11. Chance to Check 4.

  12. Chance to Check - content • Identifying 4 key statements that must be self asked on each administration • Prompt cards can be used initially but should become automatic. • Every patient, every time deliberate design.

  13. Chance to Check – time / focus • Take the time to get the task right • Do the right checks • Acts like a pause in the process • Raise awareness of medication issues • Prompt ward discussion • Standardising approach

  14. Additional Points – No interruptions • Signage • On admission • Communication book • Agreement on acceptable interruptions • Be strong and united

  15. Additional Points - BNF • One on each trolley • Up to date • Labelled

  16. Post Round Sweep Reduce errors relating to medicines; • Omitted / forgotten / lost • Taken late • Taken by other patients Your drug round – your responsibility.

  17. Promote ward discussion • When & Who? • Incidents feedback • Review Chance to Check • Praise

  18. Implementation • Pilot wards • Spread to other wards in S&A • Taken to Heads of Nursing and spread to other directorates • Included in MyMeds project • Recently introduced to 3rd year undergraduates

  19. Results • Staff like it • Feel they have permission to do the right thing • Feel they are using nursing knowledge • Feel more assured the process is good • Less interruptions

  20. Any Questions?

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