An audit carried out by the author on her recent practice placement. The practice placement was in a continuing care unit which cared mainly for patients who were at the end stages of life. The author decided to choose safe drug administration
Clinical Audit.
This essay intends to focus upon an audit carried out by the author on her recent practice placement. The practice placement was in a continuing care unit which cared mainly for patients who were at the end stages of life. The author decided to choose safe drug administration for her audit for a number of reasons.
The unit had 24 beds with one qualified nurse caring for 12 patients each. Due to the complex health needs of individuals, many patients required several medicines at varying times of the day. The author felt that as these patients required more complex drugs regimes this gave a greater scope for drug errors to occur. Looking along the lines of human error, the author noted that the staff nurse on duty often worked 14 hour days and Fitzpatrick and While (1999) report that nurses overall clinical performance is significantly greater when working a traditional 8 hour shift compared to a 12+ hour shift.
Medication errors can not only be harmful to the patient but it is estimated that inpatient drug errors can cost the NHS £410 million per year. This figure does not include litigation costs which are thought to be conservative at £750 million per year (National Patient Safety Agency, 2007).
To ascertain what the standards should be for the clinical audit the author first looked at current guidelines and policy from varying sources and then applied them to her area of clinical practice. To keep the audit manageable, the administration of regular drugs was chosen as the area to be audited and only drugs give orally was monitored. The administration of controlled drugs or 'as required' drugs was not observed. Different criteria would have had to have been observed if taking in to account various routes of administration and whether the drug was controlled or not.
The author chose to break down the process of regular, oral drug administration in to 5 areas and looked at relevant literature to support each individual standard. The audit itself was carried out over 2 drugs rounds at different times of the day and by 2 different staff nurses. Each drug round consisted of 12 patients.
Standard 1 - Wash hands with both soap and water or bactericidal alcohol hand rub before administering drug to patient.
The rationale behind standard 1 is to minimize the risk of cross infection. The NMC (2006) reasons that infection control precautions underpin safe clinical practice. The Department of Health (DoH) (2006) specifies further that hand hygiene should be carried out immediately before contact with every patient and that the very old and the chronically sick are more susceptible to infection.
Standard 2 - Before administration of any drug, check the medicine kardex for the following: the drug is due, has not been given already, information is complete, correct and legible.
Within this standard there are many factors to be checked and these should include the dose, the drug, date and time of administration, validity of prescription, signature of doctor and that the kardex is legible. Dougherty and Mallett (2001) state that the kardex should be checked thoroughly on every occasion to prevent harm to the patient; to ensure that the patient is given the correct drug, via ...
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Standard 2 - Before administration of any drug, check the medicine kardex for the following: the drug is due, has not been given already, information is complete, correct and legible.
Within this standard there are many factors to be checked and these should include the dose, the drug, date and time of administration, validity of prescription, signature of doctor and that the kardex is legible. Dougherty and Mallett (2001) state that the kardex should be checked thoroughly on every occasion to prevent harm to the patient; to ensure that the patient is given the correct drug, via the correct route and at the appropriate dose. The NPSA (2007) found from their studies that 57.3% of all medication incidents were accounted for from this standard they include wrong dose, strength, frequency of drug, omitted medicine and wrong medicine given.
Standard 3 - Select the required medication, check the expiry date and empty the required dose into a medication pot.
Dougherty and Mallett (2001) state that drugs can deteriorate with storage and the administration of drugs past their expiry date can be dangerous. By emptying the drug in to a medication pot without touching the drug, good infection control is maintained.
Standard 4 - Take the patients medicine and kardex to the patient and confirm their identity by asking the patient to confirm their name and date of birth or by checking their wrist band.
As mentioned previously a study by the NPSA (2007) found that 11.5% of drug incidents occurred when the wrong medicine was given. This can be prevented by checking your patients details match that on the kardex.
Standard 5 - Administer the medicine, offering water if allowed and record in the drugs kardex the dose given.
The NMC (2004) states that a clear record of medications given, refused or withheld from the patient are recorded immediately. This allows the next person giving medication to know what the patient has had previously and can prevent drug errors.
Safe recording of drug administration is a legal requirement.
Findings:
Overall, the results from the audit carried out showed that practice achieved what was set out in the standards. The only standard which showed the most variance in outcome was that of standard 4. The author will analyse the findings from the audit by dividing the results in to the standards they were audited against.
Standard 1:
The findings from this standard showed that both nurses maintained good infection control procedures by using alcohol gel between patients. In only 2 instances did nurse 1 omit to wash her hands. However, there was no patient contact as neither patient required assistance to take their medication and both of the said patients were in the dining room having lunch when the medication pot was left on the table for them. It could be argued that nurses are very much aware of the need to wash their hands when coming in to contact with patients. Poster campaigns to wash our hands and the awareness that patients and their relatives have of infection control could be the reason why this standard was so well adhered to. Alcohol gel was used between patients and not soap and water. This makes maintaining infection control easier and quicker.
Standard 2:
The findings from this standard showed 100% adherence from both nurses. The NMC Code of Professional Conduct (2004) states that nurses must practice competently by possessing the skills, knowledge and abilities to act in a safe and lawful manner. By checking the kardex thoroughly before the administration of medication they are not only protecting the patient but protecting themselves and their registration.
Standard 3:
The findings from this standard showed fairly good adherence from both nurses. Both nurses maintained good infection control and selected the correct medication from the drugs trolley. I didn't observe them checking for the expiry date on 3 occasions each. Reasons could include the author not noticing them look for the expiry date or it could have been due to the fact that they had just administered the drug to a previous patient and knew it was in date.
Standard 4:
This standard showed very little adherence from both nurses. When questioned why they didn't take the kardex to the patient the author was informed that the residents on the unit were to be treated as much as possible like they were in their own home. A name badge was on each resident's door and because the residents had been on the unit for a long time the staff knew definitely that the medication they were giving was going to the correct person. This is a logical reason for not adhering to the standard however, the author did not view the unit's policy so is unable to comment on whether this was an official view taken by the unit or the opinion of the nurse administering the medication.
Standard 5:
The results from this standard also achieved 100 % compliance. It was found that once the drug had been administered the nurse would return to the drugs trolley and write on the kardex whether the patient was able to take the drug or if they weren't they wrote the reason why. This is again good practice, it is a legal requirement to write the dose given and at the time given also. As nurses we are accountable for our actions. Without writing down what we have done for the patient, who is to know it was done at all? By writing down the correct information on the kardex, the nurse was ensuring not only the patients safety but maintaining her own professional practice.
The majority of the results were favourable to the standards set out. Maintaining high levels of care in this area of nursing is important for patient safety and costs to the NHS. This level of care could be maintained by ensuring that nurses are aware of clinical guidelines and remain up to date with current policy. Craig and Smyth (2007) suggest that by following guidelines we can ensure safe practice, improve consistency of care and that care being delivered is evidence based. However, it could be argued that yes guidelines do ensure the above but it should be necessary also for the nurse herself to have a thorough knowledge base of the task she is to carry out.
This unit was unique in that each client had their own individual room which they rarely came out of due to their terminal condition. The nurses weren't disturbed during the drugs round and this could have been a factor in the adherence to the standards set. A trial featured by the Clinical Governance Support Team (2007) talked about letting nurses wear tabards to state they were doing the drugs round and did not want to be disturbed. This trial shows that some trusts are looking to reduce drug errors and are looking to reduce future drug errors.
Having access to resources on the unit could improve or maintain good standards of care. An up to date BNF could provide nurses with knowledge about drugs they have not come across before and whether they have any contraindications.
Drug administration is the final step in a multidisciplinary process so blame for drug errors can not always be blamed on the individual giving the drug. Collaborating with other health professionals such as doctors and pharmacists could reduce any potential drug errors and make the process of drug administration safer and easier.
From carrying out this audit the author has found that drug errors can have massive implications to the patient, the nurse and to the NHS. It is important to be thorough and have a sound knowledge of the drugs being dispensed. It will affect the author's future nursing practice by strengthening her knowledge in not becoming complacent or familiar with the drugs round. As mentioned before the unit was privileged in that they could get to know their patients over long periods of time but this can not be said for every future practice placement.
References:
Craig J and R Smyth (2007) The Evidence-Based Practice Manual for Nurses 2nd Edition Elseiver: London
Clinical Governance Support Team 2007 available at: http://www.cgsupport.nhs.uk, accessed on 09/06/07
Department of Health 2004, Building a Safer NHS for Patients: Improving Medication Safety.
Department of Health 2006, Infection Control Guidance for Care Homes, Available at: www.dh.gov.uk/publicationspolicyandguidance accessed on 09/06/07
Dougherty and Mallett 2001, The Royal Marsden Manual of Clinical Nursing Procedures, Blackwell Sciences: London
Fitzpatrick and While 1999 - Shift work and its impact upon nurse performance: current knowledge and research issues, Journal of Advanced Nursing 29(1) pp18-27
National Patient Safety Agency, 2007 Safety in Doses: Medication Safety Incidents in the NHS available at www.npsa.nhs.uk accessed on 09/06/07
The NMC 2004 Code of Professional Conduct, London
The NMC 2004 Guidelines for the Safe Administration of Medicines, London
