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Safe Medication Prescribing in Halton Memory Services

Published online by Cambridge University Press:  01 August 2024

Divya Jain
Affiliation:
Merseycare NHS Trust, Halton, United Kingdom
Archisha Marya*
Affiliation:
Liverpool University, Liverpool, United Kingdom
*
*Presenting author.
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Abstract

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Aims

  • To improve safe medication prescribing by achieving a 25% improvement in the number of cases reported in the practice within six months.

  • To reduce human factors contributing to medication errors to improve patient safety and quality of care.

Methods

  • Retrospective data collection was done for Halton and Widnes patients from March 2022 to April 2023;

  • Retrospective data collection for Re-audit was done for a period between June 2023 to January 2024 to complete the audit cycle;

  • Liaised with medicine management team for local practices/policies;

  • Reviewed and verified Trust standardised local policies on medicine management;

  • Reviewed incident data and checked processes in other teams;

  • The findings were presented at the Medicine Management meeting in May 2023;

  • Training on safe prescribing was delivered to the Memory team in June 2023.

Results

  • During the first data collection period, 14 incident forms were reported.

  • During the second data collection period, 1 incident form was reported which was an administrative error.

  • Prescribing errors for the first cycle accounted for 28.6%, administrative errors for 35.7%, dispensing errors for 21.4%, and other errors for 14.3%.

  • Specific error types included prescribing the wrong dose/medication, medication not prescribed, medication unavailable and double prescribing.

  • No incidents of restraint, seclusion, rapid tranquillisation, ambulance calls, or RIDDOR were reported.

Conclusion

  • Administrative errors accounted for the majority of the total reported incidents (35.7%).

  • Recommendations include safe clinical practice of prescribing medication (MDT lead to update medication card and inform GP promptly).

  • Other recommendations were medication card updates, aligning clinical systems, avoiding email requests and introducing Community EPMA (Trust objective to introduce EPMA to community teams in 2024/25) and to standardise procedures.

  • An improvement of 92.9% in the incident reporting was found in the re-audit following a training session to the team with improved practice of no email requests or chains.

  • The audit identified communication difficulties within memory services, primary care and care home.

  • It also highlighted challenges related to new staff, post-MDT meetings medication card updates, prescriber preferences, geographical disparities, and doctors’ availability.

Type
3 Quality Improvement
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © The Author(s), 2024. Published by Cambridge University Press on behalf of Royal College of Psychiatrists

Footnotes

Abstracts were reviewed by the RCPsych Academic Faculty rather than by the standard BJPsych Open peer review process and should not be quoted as peer-reviewed by BJPsych Open in any subsequent publication.

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