Yes / Medication errors involving insulin in hospital are common,
and may be particularly problematic at the point of transfer
of care. Our aim was to improve the safety of insulin
prescribing on discharge from hospital using a continuous
improvement methodology involving cycles of iterative
change. A multidisciplinary project team formulated
locally tailored insulin discharge prescribing guidance.
After baseline data collection, three ‘plan-do-study-act’
cycles were undertaken over a 3-week period (September/
October 2018) to introduce the guidelines and improve the
quality of discharge prescriptions from one diabetes ward
at the hospital. Discharge prescriptions involving insulin
from the ward during Monday to Friday of each week were
examined, and their adherence to the guidance measured.
After the introduction of the guidelines in the form of a
poster, and later a checklist, the adherence to guidelines
rose from an average of 50% to 99%. Qualitative data
suggested that although it took pharmacists slightly longer
to clinically verify discharge prescriptions, the interventions
resulted in a clear and helpful reminder to help improve
discharge quality for the benefit of patient safety. This
project highlights that small iterative changes made by a
multidisciplinary project team can result in improvement
of insulin discharge prescription quality. The sustainability
and scale of the intervention may be improved by its
integration into the electronic prescribing system so that
all users may access and refer to the guidance when
prescribing insulin for patients at the point of discharge.
| Identifer | oai:union.ndltd.org:BRADFORD/oai:bradscholars.brad.ac.uk:10454/17500 |
| Date | 07 November 2019 |
| Creators | Bain, A., Silcock, Jonathan, Kavanagh, S., Quinn, Gemma L., Fonseca, I. |
| Publisher | BMJ |
| Source Sets | Bradford Scholars |
| Language | English |
| Detected Language | English |
| Type | Article, Published version |
| Rights | © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. |
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