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Improving drug chart documentation in elective surgical patient admissions.

机译:改进选择性外科手术患者入院的药物图表文档。

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摘要

National Institute for Health and Care Excellence (NICE) guidelines state that all healthcare organisations should put policies in place for medication reconciliation on admission. At Croydon University Hospital a medication history had previously been taken in Foundation Year 1 (FY1) preoperative clinics. However, when these clinics were deemed unnecessary, this opportunity for drug chart documentation was lost, along with an awareness of this responsibility among the FY1s. As a result patients were being admitted to wards without adequate drug chart documentation which resulted in a serious untoward incident occurring. This project aimed to increase awareness among FY1s of this responsibility and as a result increase drug chart documentation in postoperative elective surgical patients.The drug charts of 40 postoperative elective surgical patients admitted to all surgical wards were reviewed over a 2 week period. 12.5% (4/32) of patients taking regular medication had these correctly prescribed, with ‘high risk medication omissions’ found in 7.5% (3/40). Documentation of an allergy status was absent in 17.5% (7/40) of patients, including 5% (2/40) of whom had a known drug allergy.To create awareness of this responsibility, first, a presentation was given to the FY1s, second, posters to prompt action were placed on the elective surgical wards, and finally, the Director of Medical Education emailed the FY1s reiterating these facts. We then reviewed the drug charts of 45 elective postoperative patients over a 2 week period following these interventions.The results showed: correct prescription of regular medications improved to 48% (16/33); ‘high risk medication omissions’ reduced to 4% (2/45); documentation of allergy status on the drug charts increased to 87% (39/45); failure to document a known drug allergy on the drug chart fell to 2% (1/45); and patients with a ‘high risk medication omission’ or an undocumented known drug allergy decreased from 12.5% (5/40) to 7 % (3/45).This study has highlighted an area in which medication reconciliation and drug chart documentation were inadequate, and posed a risk to patient safety. Interventions designed to educate the FY1s and inform them of their responsibility improved standards in regular medication prescription and allergy documentation. However, leaving the onus with the FY1s was not enough to achieve adequate drug chart documentation. Further project cycles may therefore require the implementation of a step within the patient admission protocol in the preoperative ward that requires the nursing staff to contact the team's doctor when the patient arrives in hospital to ensure satisfactory drug chart documentation. In addition, collaboration with the pharmacists could also allow a ‘best possible medication history’ to be taken on the day of admission and thus reduce risk to patient safety.
机译:美国国家健康与护理卓越学院(NICE)指南指出,所有医疗机构都应在入院时制定有关药物对账的政策。在克罗伊登大学医院,以前在基金会第一年(FY1)的术前诊所就曾接受过药物治疗史。但是,当这些诊所被认为是不必要的时,失去了进行药物图表记录的机会,并且在FY1中也意识到了这种责任。结果,患者被送往病房,但没有足够的药物图表记录,导致发生严重的不愉快事件。该项目旨在提高FY1对此责任感的认识,并因此增加术后择期手术患者的药物图表记录。在2周的时间内对40名接受所有外科病房的术后择期手术患者的药物图表进行了审查。接受常规药物治疗的患者中有12.5%(4/32)的处方正确无误,其中7.5%(3/40)的患者发现“高风险药物遗漏”。 17.5%(7/40)的患者中没有过敏状态的记录,其中5%(2/40)的患者具有已知的药物过敏。为了增强对此责任感的认识,首先,对FY1进行了介绍。其次,在外科手术病房上张贴了迅速采取行动的海报,最后,医学教育总监通过电子邮件向FY1重申了这些事实。然后,我们回顾了这些干预措施后2周内对45名择期术后患者的药物图表。结果显示:常规药物的正确处方提高到48%(16/33); “高风险药物遗漏”降低到4%(2/45);药物图表上的过敏状态记录增加到87%(39/45);未能在药物图表上记录已知的药物过敏降至2%(1/45);患有“高风险药物遗漏”或未记录的已知药物过敏的患者从12.5%(5/40)下降至7%(3/45)。该研究突出显示了药物调和和药物图表文档不足的领域,对患者的安全构成威胁。旨在对FY1进行教育的干预措施,并告知他们责任,他们在常规药物处方和过敏文档中提高了标准。但是,让FY1承担责任不足以实现足够的药物图表记录。因此,进一步的项目周期可能需要在术前病房的患者入院规程中执行一个步骤,该步骤要求护理人员在患者到达医院后与团队的医生联系,以确保获得满意的药物图表记录。此外,与药剂师的合作还可以允许在入院当天记录“最佳可能的用药史”,从而降低患者安全的风险。

著录项

  • 期刊名称 BMJ Open Quality
  • 作者

    Alice Thompson;

  • 作者单位
  • 年(卷),期 2014(2),2
  • 年度 2014
  • 页码 w893
  • 总页数 3
  • 原文格式 PDF
  • 正文语种
  • 中图分类
  • 关键词

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