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
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
Focus Groups - medication round • Not enough time • Debate about who should do it • Lost importance • Feels very task driven • Underlying concern
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
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
Chance to Check - content • Identifying 4 key statements that must be self asked on each administration
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.
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
Additional Points – No interruptions • Signage • On admission • Communication book • Agreement on acceptable interruptions • Be strong and united
Additional Points - BNF • One on each trolley • Up to date • Labelled
Post Round Sweep Reduce errors relating to medicines; • Omitted / forgotten / lost • Taken late • Taken by other patients Your drug round – your responsibility.
Promote ward discussion • When & Who? • Incidents feedback • Review Chance to Check • Praise
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
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