VOL: 98, ISSUE: 37, PAGE NO: 36
Brigid Reid, MPhil, BN, CertEd, RGN, is nurse consultant - general surgery, Blackburn, Hyndburn and Ribble Valley Health Care NHS Trust
Ruth Townson, BSc, DipHSM, MRPharms, is assistant director of pharmacy services, Blackburn, Hyndburn and Ribble Valley Health Care NHS Trust;Hazel Renton, BTec Apoth.Hall, DipIM, is chief pharmacy technician, Blackburn, Hyndburn and Ribble Valley Health Care NHS Trust;Adele Shiel, SRN, NNEB, DMS, is ward sister, Blackburn Royal InfirmaryA review of drug administration was carried out at Blackburn Royal Infirmary as part of work to inform a practice-development strategy in the directorate of general surgery. It found that, as in most of the trust's wards, drug administration involved patients receiving their medicines during drug rounds, which were done by nurses who dispensed them from a large drug trolley.
A review of drug administration was carried out at Blackburn Royal Infirmary as part of work to inform a practice-development strategy in the directorate of general surgery. It found that, as in most of the trust's wards, drug administration involved patients receiving their medicines during drug rounds, which were done by nurses who dispensed them from a large drug trolley.
This can pose a number of problems, including:
- It is often difficult to locate the right medication as the trolley is so full;
- The nurse is likely to be interrupted frequently as, instead of being behind a curtain or dealing with a single patient, he or she is in full view of everyone;
- The nurse may not be aware of individual histories, such as associated medical conditions or pain, because he or she is not caring for particular patients directly.
Internal auditing and feedback from both the pharmacy and clinical incident reporting revealed that these problems were having an impact on patient care in terms of drug errors or narrow misses. There was also anecdotal evidence that:
- Patients were not always receiving their medication at the most appropriate times;
- Because the administration of medicines was part of a round there was limited time to ensure that patients understood what medications they were taking and why.
Such regimented practice did not fit in with the ethos of patient-centred care and empowerment that is central to the development of practice in the directorate. Binnie and Titchen (1999) explain the concept by saying: 'Patient-centred nurses will still make observations, collect specimens and administer drugs to help doctors with their main task of diagnosing and treating disease, but this forms only a small and relatively simple part of nursing work. Within this style of practice, the nurse's major concern is understanding what disease means for patients and helping them and their families with its consequences.'
Such work can be complex and demanding. It requires intelligence, creativity and careful, sensitive attention to detail. For the nurse, it can be immensely rewarding. For the patient, it can mean the difference between being sent home as a mended body or as a healed person (Binnie and Titchen, 1999).
One of the key findings of a large-scale ENB research project (Latter et al, 2000) was that a nurse's ability to educate patients about their medication was enhanced when 'the practice setting had a person-centred philosophy of care, and where continuous and therapeutic nurse-patient relationships were enabled to develop'.
Although The NHS Plan stipulates that one-stop dispensing is a target for all hospitals, this requires a considerable investment in time and money.
The trust estimated that this would take about two years to achieve, prompting the pharmacy and the directorate of general surgery to agree to set up a pilot scheme for patient-centred drug administration (PCDA) on a 21-bed surgical unit.
Setting up the pilot
A project steering group that included staff involved in research and development, and the dispensing, prescribing and administration of medicines (Box 1) was convened to devise a new system. This took about six months from planning to implementation. The pilot ran for six weeks and was then evaluated.
The following actions were taken after being discussed by the steering group and following a site visit to Arrowe Park Hospital, Wirral Hospital NHS Trust, a trust that has adopted a similar system of drug administration:
- Individual medicine cabinets were bought and installed at patients' bedsides;
- A prepilot audit of practices related to medicine rounds was carried out;
- Ward stock levels were reviewed to ensure an adequate supply of drugs for each locker, such as analgesics, laxatives and commonly used antibiotics;
- Information for staff (Box 2) was placed next to patients' prescription charts;
- Information for patients was placed near their beds.
In addition, steps were taken to increase staff understanding of what constituted a 'drug error' and of their professional accountability in relation to drug administration. The scheme used ward stocks of medications and individually dispensed items. The drug trolleys were taken out of use after the medication lockers had been installed next to patients' beds.
Evaluation of the pilot
A multimethod approach was adopted to examine the effects of switching to the new system. This included:
- An analysis of the timing/interruptions of drug administration before and after the changes;
- Two spot audits of each patient's chart, cabinet and awareness of the new system;
- A staff questionnaire about the pilot;
- Observations of practice, staff notes and patient comments.
Several aspects of the system were evaluated, including whether it saved time, the risk of errors, its ability to offer integrated individualised care and the opinions of staff.
The data indicated that although the system did not actually save time there was a perception that it did.
The risk of errors
Two spot audits revealed that although most patients had the right drugs from stock that had been dispensed individually, there were occasions when medication that belonged to a previous patient was left in the locker or medicines that patients had brought from home was not identified as separate from those supplied by the hospital.
Ability to offer integrated individualised care
As part of directorate's development work, two non-participant observers recorded the care of a group of patients during a 14-hour day towards the end of the pilot. This provided useful data.
They noted that a nurse saw each patient, checked their charts, offered medication and discussed issues with them. Up to 10 minutes later the nurse was followed by a nursing student who observed the patient's vital signs. The observers noted that the administration of medication and the observations were viewed as separate activities, so the opportunity to offer patients seamless care was being lost. This highlighted a need for further study.
Subsequent observations showed that the project enhanced the individual allocation and follow-through of a group of patients by identified nurses.
The opinions of staff
Staff opinions were collected by means of a questionnaire distributed to all nurses on the unit and the two pharmacy staff supporting the project. Other comments from them were included. Of the 17 questionnaires distributed, only seven were returned.
There were no negative views on the new system. Although a couple of respondents described it as 'not too bad' or 'all right'. Most described the new system as 'good', saying it was much easier and more personal. The pharmacy staff noted improvements, saying they felt part of the team, and noted that the drugs stocked were both relevant and sufficient.
Staff perceptions of the PCDA system ranged from descriptions of the system being 'more patient-centred' and individualised to the 'right drug, right patient, right time' approach. With only one exception, the respondents had an appropriate understanding of the system. Concerns that they would confuse the concept with self-medication appeared to be unfounded.
When asked what they felt was particularly advantageous about the system, two mentioned the involvement of patients and the individualised approach. Others said it saved time, resulted in fewer interruptions and reduced the risk of errors as patients' medication was easy to identify. One of the pharmacy staff noted that the system made it easier to replenish stocks as they did not have to wait for the trolley round to finish.
More than half the respondents said they could not identify any disadvantages. Minor criticisms included the location of lockers, which could be difficult to access when there were other people around the bed.
Proposals included remembering to empty the lockers when patients were discharged, and stocking them appropriately for new patients or when new drugs were prescribed. These points echo the findings of the spot audits and the time analysis. Laminated notices to this effect have now been attached to the front of each locker.
Because the patient population changes so frequently, attempting to elicit views before and after the project to provide a comparison would not have been meaningful. Although there had not been any complaints about the system, a few patients had complained about 'being at the end of the round' and the timing of analgesia. Throughout the pilot, direct comments from patients to the auditor and those fed back by staff were noted.
The pharmacy staff, in particular, reported how frequently patients commented on the system. These included: 'They felt happier that they received the right drug at the right time and felt they were involved with the administering of their medication'; 'They expressed that they felt happier as they knew there was a reduced risk of an error in drug administration'.
Implications for practice
Although the evaluation identified that certain aspects of the system needed adjustment, it was agreed that it would be adopted by the unit and introduced elsewhere in the directorate. A suggestion, to test the reaction, that the system might not be adopted provoked a passionate response.
The evaluation enabled us to identify key aspects to focus on when implementing the system on other wards, such as the need for:
- Time to establish the fundamental principles of the system and its link to other developmental work, ensuring that the chance to integrate drug administration with other aspects of care is not lost and preventing the system from being confused with self-medication;
- Attention to detail and commitment to colleagues to ensure that time is not lost if adequate supplies of pots or medicines are not in a patient's locker;
- An agreed discharge/transfer procedure to ensure that patients' medicine lockers are emptied and medications are dealt with appropriately;
- A procedure to ensure that a patient's own drugs (those not being used by the hospital with the pharmacist's agreement) are kept separately in the locker or elsewhere;
- Consideration of the location and use of information sheets for patients;
- A system to remind and update the staff's knowledge base on pharmacology and professional accountability.
The project clearly has the potential to improve patient outcomes, although these have not been evaluated specifically at this stage. It has shown how a collaborative and systematic approach to practice development (Kitson et al, 1998) enables effective, sustainable and evolving change.
Although we do not yet have one-stop dispensing systems, the use of patients' own medications or self-medication, the project has given us a sound basis on which to develop these systems. In the meantime, we have transformed a powerful symbol of traditional, task-focused practice - the medicine round - into a system that has the potential to improve patients' experience and the outcomes of care.