Dolores Keating MPSI Head of Pharmacy PHOTOGRAPH HERE Dolores Keating MPSI Head of Pharmacy From Pen to Patient: Improving Prescription Writing Practice at a Psychiatric Teaching Hospital

Why Prescription Writing? Medication errors are one of the most common causes of patient harm1 Poor prescription writing is a factor National and international patient safety issue Baseline audits in Irish hospitals show low rates of adherence to good practice guidelines2-5 Quality improvement processes including audit and feedback, educational initiatives, improving medication charts and multidisciplinary working can raise standards3-7 Sustaining improvements is a challenge NPS, UK, 2009 www.npsa.nhs.uk Farooq et al, It J Med Sci, 2008; 177; 243-245 Ahmed a et al, Ir J Psych Med 2011; 28(2): 84-86 Tully et al, Ir J Psych Med 2010; 27(2): 82-85 Bates et al, Ir J Med Sci: 2010; 179: 183-186 Dornan et al, EQUIP Study, 2009; www.gmc-uk.org Health Foundation, UK, 2012; www.health.org.uk

Audit Criteria Allergy documentation Generic prescribing Handwriting: written in block capitals or un-joined lower case Start date Discontinuation process completed Patient name and MHIS number on each page (2012) Prescribers signature bank and MCRN completed (2012) PRN Medications Dose specified Interval specified with maximum frequency in 24 hours Weekly review of PRN medications documented (2012)

Sampling STANDARD Every 4th name on an alphabetical list 25% of inpatient cohort over one week N=40 to 50 Some standards may not apply to all charts e.g. if no PRN medication prescribed STANDARD 100% adherence within the entire chart with the criteria Exceptions defined Brand name of a product that is not inter-changeable e.g. Priadel ® ‘nocte’ for frequency of hypnotic in PRN section

Interventions Pharmacists screening medication charts Reinforcement of Standards Medication safety event reports analysed Dissemination of Guidelines Active and Passive Feedback Pre-audit Introduction of a new medication charts Dissemination of Good Prescribing Practice Guidelines Baseline 2010 Intensive targeted feedback Re-audit Good Prescribing Practice Education Review of Medication Chart 2012 Good Prescribing Practice Education Mandatory Re-audit 2013 Pilot targeted feedback for PRN review Improved medicines reconciliation Re-audit 2014 Targeted feedback for Prescribers Signature and PRN standards Format of Good Prescribing Practice Education Reviewed Liam neeson Periodic e-mails

Targeted Feedback

Targeted Feedback

Education Small group teaching Give relevant examples of why it is important to prescribe generically

Review of medication Chart Draft HSE/State Claims Agency/Mental Health Commission Guidance for design & Governance of the Mental Health in- patient Medication Prescription & Administration Record (MPAR) 2012 National HSE MPAR Guidelines for Acute Hospitals 2012 Standards for the design of Hospital in-patient prescription charts UK: Academy of Medical Royal Colleges, Royal College of Nursing, Royal Pharmaceutical Society UK National In-patient Medication Chart Standards, Australia

Prompt to clarify time of administration

Prompt for rewriting chart during normal working hours

Layout of PRN section

Layout of PRN section

Supplementary charts

Medicines Reconciliation Allergy documentation

Results

Results

Results

Challenges Labour intensive Turnover of medical staff Sustainability Audit standard Passive dissemination of guidelines and feedback Different prescription charts and guidelines across the mental health services Education alone didn’t have the desired effect Particularly difficult to get compliance with local standards Easiest thing to do

What worked? Improve prescription charts Prescription monitoring by pharmacists Medicines reconciliation Audit and active feedback Education Multidisciplinary working Leadership Support at governance level Patient safety culture Dynamic continuous quality improvement process The leader can change but someone needs to pass on the baton

Where to now? Medicines Management in Mental Health Education National Guidelines Electronic Prescription Writing System Continue to integrate pharmacists into mdts finalised. Excellent bespoke epr and electronic rx writing is on that IT development plan. Electronic systems when well designed and well maintained and we are in a good position to inform that development process.

Thank you Cathy Shelley Stephen Boss Brid O’Meara Ruairi Corkery Aoife Davis Audrey Purcell Lorna Dillon Caroline Hynes Aoife Carolan Ciara Dowling De Abbie Lane Dr Susan fletcher Jones Dr Rory Shelley Dr Stephen McWilliams Dr Brendan Cassidy