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Safe Treatment and Administration of Medicines in Paediatrics (STAMP)

Multi-faceted quality improvement project aiming to improve medication safety in a DGH paediatric department.

The problem

We noted that a significant number of clinical incidents reported in our department were medication errors. A review into one particular drug error led our team to decide that an overarching multidisciplinary approach to the problem was needed, covering safety culture, prescribing, administration and medicines reconciliation. We wanted it to be a grass roots project, tackling concerns that staff on the ground had indentified as barriers to medication safety, including human factors, system problems and education.

Aims

1. Reduce preventable adverse drug events by 25% year on year.2. Reduce the prescription error rate (defined as the number of errors identified by a pharmacist per 100 new prescriptions).

Making the case for change

Multidisciplinary team members (nursing and medical staff from paediatric A&E, Neonatal Unit and Children's Ward and pharmacists) invited to focus groups examining what they felt were barriers to medication safety together with potential solutions. Programme Management Team were involved to assist with structuring the project including development of GANTT chart. 

Your improvement

The project team ranked proposals from focus groups according to impact and achievability and identified 6 interventions for the first STAMP cycle:Safety huddles, Use of red tabards during drug checking, Window in drug room door to reduce interruptions, Monitoring of prescription error rates by pharmacist, Photo feedback of prescription errors to prescriber and Paediatric Prescribing E-learning for doctors.Champions within each staff group were identified and involved in planning the interventions using the PDSA approach. An official launch was arranged attended by senior management with support of the Trust Communications Team during which the project video was shown.The project is currently in the 'study' phase of the first PDSA cycle. Data is being collected on the prescription error rates. Medication incident report rates and numbers of preventable adverse drug errors reported will be anlaysed based on number of admissions, as we have recently had increased admissions due to a local reorganisation. The components of the project will be monitored separately - e.g. monitoring prescription error rates as found by the pharmacist on her rounds, auditing use of the red tabards by nursing staff during their drug checking and safety hurdles. 

Learning and next steps

We will be more proactive in recruiting new medical staff as champions at induction, due to the high turnover of junior doctors. We are now showing the project video to all new staff at relevant induction sessions. Involvement of IT was extremely helpful as a tablet device was issued to the paediatric pharmacist to help her collect information on error rates and photos of prescription errors to be fed back to the prescriber.As we go round the PDSA cycles we will decide which interventions to continue and consider whether to introduce any new interventions. 

Quality assurance/MHRA Registration

The project has had the support of the Trust's Director of Nursing, Lead for Quality and Safety and the Department's Clinical Governance Lead. Once a PDSA cycle has been completed and sufficient data collected the project will be submitted for a peer reviewed publication.