University Hospitals of Leicester NHS Trust

Medication Safety Thermometer: The benefits of implementation at University Hospitals of Leicester NHS Trust

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University Hospitals of Leicester NHS Trust are one of the biggest and busiest NHS Trusts in the country, serving the one million residents of Leicester, Leicestershire and Rutland – and increasingly specialist services over a much wider area – with a mission to deliver ‘Care at its best’.  Their nationally and internationally-renowned specialist treatment and services in cardio-respiratory diseases, cancer and renal disorders reach a further two to three million patients from the rest of the country. 

Liz McKechnie, Medication Safety Lead Pharmacist at UHL, has given us this feedback on the benefits they have seen from their Medication Safety Thermometer roll out.

Background

“Over the last 6-9 months we have been using the medication safety thermometer across all adult in patient wards. This has helped us to monitor how we are doing against various key safety issues; documentation of allergies, medicines reconciliation and particularly omitted doses.  

In 2010 the NPSA issued the alert ‘reducing harm from omitted and delayed medicines in hospitals.’ This is an area which as a Trust we have struggled to reduce and have still seen serious incidents resulting from omitted doses. The alert mentioned an annual audit which we did complete but using the Safety Thermometer has replaced this and allows us to monitor with increased frequency and target areas of concern.

Only 25% of our wards have electronic prescribing so data is not readily available in any other format. We have created a dashboard at all levels; Trust, Clinical Management Group and individual ward level. All wards can see their results and compare with others using the dashboard and then discuss with teams, resulting in an increased awareness of the problems with omitted doses.” 

Integration of Safety Thermometer and improvement work

Screen Shot 2015-08-13 at 13.59.42“We have a series of interventions planned to tackle omitted doses and will use the Safety Thermometer to measure the impact. The Safety Thermometer does not monitor all critical medicines but if generally omissions decrease then we are hoping that this translates to all critical medicines.  We use Datix reporting to compliment the data and critical medicines incident reports have decreased since the introduction of the Safety Thermometer.

One of the most important results of using this as a tool has been the engagement with nursing colleagues who collect the data and so can see the issues on their own ward. The comment from the sister of the ward we first trialled it on was that ‘omitted doses were not an issue on the ward.’ This rapidly changed following the first audit and she could see the value of collecting the data.

To date we have not yet attempted to categorise the level of harm for patients who have triggered, with anticoagulants and insulin being our highest triggers. This is our next step and we have engagement from the diabetes team who are keen to use the results as one of many data sets to review their plans to improve safety for insulin use in diabetics. “

Encouragement for other Trusts

“I would encourage Trusts to use the Medication Safety Thermometer. One of the greatest benefits is that medication safety is now discussed monthly at various Trust meetings and has now become part of the Trust’s quality commitment.”