Safe Medication Prescribing in Halton Memory Services

Abstract

Aims

• • To improve safe medication prescribing by achieving a 25% improvement in the number of cases reported in the practice within six months.

• • To reduce human factors contributing to medication errors to improve patient safety and quality of care.

Methods

• • Retrospective data collection was done for Halton and Widnes patients from March 2022 to April 2023;

• • Retrospective data collection for Re-audit was done for a period between June 2023 to January 2024 to complete the audit cycle;

• • Liaised with medicine management team for local practices/policies;

• • Reviewed and verified Trust standardised local policies on medicine management;

• • Reviewed incident data and checked processes in other teams;

• • The findings were presented at the Medicine Management meeting in May 2023;

• • Training on safe prescribing was delivered to the Memory team in June 2023.

Results

• • During the first data collection period, 14 incident forms were reported.

• • During the second data collection period, 1 incident form was reported which was an administrative error.

• • Prescribing errors for the first cycle accounted for 28.6%, administrative errors for 35.7%, dispensing errors for 21.4%, and other errors for 14.3%.

• • Specific error types included prescribing the wrong dose/medication, medication not prescribed, medication unavailable and double prescribing.

• • No incidents of restraint, seclusion, rapid tranquillisation, ambulance calls, or RIDDOR were reported.

Conclusion

• • Administrative errors accounted for the majority of the total reported incidents (35.7%).

• • Recommendations include safe clinical practice of prescribing medication (MDT lead to update medication card and inform GP promptly).

• • Other recommendations were medication card updates, aligning clinical systems, avoiding email requests and introducing Community EPMA (Trust objective to introduce EPMA to community teams in 2024/25) and to standardise procedures.

• • An improvement of 92.9% in the incident reporting was found in the re-audit following a training session to the team with improved practice of no email requests or chains.

• • The audit identified communication difficulties within memory services, primary care and care home.

• • It also highlighted challenges related to new staff, post-MDT meetings medication card updates, prescriber preferences, geographical disparities, and doctors’ availability.