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Medication delivery: Finding new ways to improve medicine administration in care homes

Caroline Maries-Tillott, Quality Improvement Lead at West Midlands Academic Health Science Network (WMAHSN), shares insights into a pilot project on medicines administration and explains what the sector can learn from the project’s findings.

Improving safety

Patient safety is at the heart of everything we do in the health and social care sector. Safeguarding patients from avoidable harm, particularly those who are considered vulnerable such as care home residents, has become a heightened priority. This is not only because of the challenges brought on by the coronavirus pandemic but also due to the growing number of residents with high support needs.

Data from recent years show as many as 90% of care home residents have high support needs – requiring additional care to manage dementia, confusion, challenging behaviour, mobility dependence, dual incontinence or severe hearing/visual impairments.

Residents with such needs rely heavily on multiple medications being prescribed correctly and efficiently and a robust and clear medicines safety framework being in place to ensure that patients are kept safe when medicated. This is why patient safety and medications management make up an incredibly important aspect in ensuring the safe care and comfort of residents with increasingly complex needs.

A multifaceted picture

A report in 2019 noted that, of the estimated 237 million medication errors occurring each year in England, 92 million of these errors took place in care homes.

With tailored care comes additional challenges and pressures on staff to get care and treatments right. The NHS is seeking to reduce severe avoidable medication-related harm by 50% by 2024 across the UK and a key element of this work is, rightly so, the safer administration of medicines in care homes.

The Care Home Use of Medicines Study (CHUMS report) published in 2009 outlined the prevalence, causes and potential harm of medication errors in 55 care homes for older people.

The report revealed an unacceptable level of medication errors relating to older people in care, with as many as seven in ten residents experiencing an error with their medicine. These errors range from doses being missed or given incorrectly, to the wrong drugs being given out. In some cases, these errors have the potential to cause very serious harm. Distractions during medicine rounds are one such potential source of error.

To mitigate the risks of harm, we must provide staff with the support and necessary resources to ensure they can better manage and reduce possible interruptions and learn from historical errors to ensure effective, long-term interventions are established to keep patients safe.

Reducing risk

At the start of the pandemic, the WMAHSN began a quality improvement (QI) programme at Marian House, a 42-bed nursing home in Sutton Coldfield. We sought to encourage safer administration of medicines and minimise interruptions to staff during medicine administration.

The project formed part of the national Medicines Safety Improvement Programme (MedSIP) and was commissioned by NHS England and Improvement (NHSE/I), and its findings will play a critical role in driving improvements nationally. The West Midlands Patient Safety Collaborative (WMPSC), which is leading this work in the West Midlands region, invited expressions of interest from care homes in the area to take part in this pioneering improvement work. Marian House submitted a request to collaboratively undertake the work to reduce interruptions to medicine rounds and was selected as the successful triallist for this project.

While it is important to recognise that not all interruptions are avoidable, particularly if there is a safety situation requiring urgent action, a lot can be done through targeted interventions.

The staff and the manager of the care home who we worked with for the trial had highlighted a particular interest in reducing avoidable harm and exploring how they could update processes and ways of working to further improve quality of care. Work quickly commenced to establish a baseline for interruption occurrences during medicine rounds with the time of day, number of interruptions and why the interruption occurred being recorded.

After this initial collection of data, the team was soon able to establish that the morning medication round saw the most interruptions – an average of three times (n = 3.45) each day – and this became a particular area of focus for developing the improvement strategy.

No time to waste

As soon as a baseline was set, the team agreed to attempt to a reduction in interruptions to rounds by a third in one month. It was critical to work with the staff in all areas and at all levels of the business, from nurses to laundry staff, cleaners to administrators, to collectively explore ways in which to change culture, practice and procedure. In a team session, we set out ideas to test to try and limit interruptions. Solutions came from across the organisation and highlighted areas in practice, staff culture and protocol, which needed to be addressed or updated to limit interruptions. Collaboratively, a list of interventions was established.

This included things such as ensuring all new staff and visitors knew how and when to escalate concerns about residents and that nurses handed over phones to care staff while doing each round. The use of a handover communication book for non-urgent messages was also included on the list of possible interventions.

Each of these interventions may sound minor but the results seen collectively during the month of implementation speak for themselves. The reduction seen in the medicine interruptions during the trial month far surpassed what the team had hoped to achieve. In fact, the seven-day rolling averages from implementation and the months that followed showed that interruptions dropped by approximately two thirds to less than one interruption per round (n = 0.87).

The project also appeared to have an impact on the safety culture within the home. Staff feedback from safety culture assessment pre and post the interruptions project showed improvement in four out of five safety domains – safety climate, stress recognition, perceptions of management and working conditions.

Team engagement

The improvements achieved at this care home represent not only a major improvement in patient safety and care quality, but a significant culture shift towards safer and more efficient medicine administration.

It’s important to note that, although the implementation of QI methods has long been used within the NHS, use within a care home setting is relatively new.

Before we embarked on this medicine safety project, literature on the use of QI methods in care homes was incredibly limited and QI data in relation to medication was rare to non-existent.

This project broke new ground, not only demonstrating the impact that QI methodology can bring to medicines-related activity in the care home sector but also in laying down the framework for how others may approach the subject.

In fact, since our test programme in the West Midlands, the project has evolved to generate automated interruptions dashboards, available to care homes across England that are looking to embark on a similar journey as part of the national MedSIP scope of work.

Although improvement tools and techniques should not be taken ‘off-the-shelf’, the dashboards provide a useful starting point for adaptation and the application of local context to each care home.

More literature needs to become available on the topic; however, results such as these breed more positive outcomes, enabling other care homes to follow on a similar journey.

COVID-19 impact

The way we consider patient safety, particularly that of vulnerable care home residents, has changed forever. Residents have long been a group of patients with complex and evolving needs and establishing best practice to ensure long-term quality of care has risen as a priority in public opinion in a matter of months.

Although there is room for more to be done, it is important to remember the tireless work that staff continue to do to ensure resident welfare. Without the support and ongoing resources that enable staff to focus on continuous QI, services will inevitably crumble under the pressures of keeping patients safe.

The pandemic has highlighted the importance of carers and care home staff and their unwavering dedication and passion to look after patients and improve care and safety. However, very few care home teams have had the opportunity to receive any formal QI training and are therefore limited in their knowledge around QI and associated areas of practice such as human factors.

By introducing care home teams to the model for improvement and by engaging them to be part of a QI project and equipping them with skills to measure improvement, they are given the opportunity to improve standards of care in their place of work. It also fosters a culture of improvement and helps them to design safer systems of working.

Ultimately, these insights will reduce avoidable interruptions to medicine rounds and support care homes in evidencing their efforts to meet the domains assessed by the CQC (particularly safe, effective, responsive and well led) and NICE recommendations 1.5 and 1.6 (reporting and reviewing medicines-related problems and keeping residents safe).

If there was ever a time to increase the support and funds to the sector to support staff in not only keeping patients safe but having the time and capacity to review ways of working, it’s now – and both patients and employees will ultimately benefit.

We chose the care occupation because we believe care matters, and the best way for us to continue to inspire and encourage the workforce of the future is to ensure we continue to improve the quality of work and the procedures that ensure the safety of patients and wellbeing of staff.

Caroline Maries-Tillott is the Quality Improvement Lead at West Midlands Academic Health Science Network (WMAHSN). Email:  Twitter: @wmahsn

About Caroline Maries-Tillott

Caroline Maries-Tillott, Quality Improvement (QI) Lead for the West Midlands Academic Health Science Network (WMAHSN) Caroline has over 30 years’ nursing experience in the NHS and has worked in critical care, professional education, safety and governance settings. She has extensive experience in leading large-scale QI programmes to build QI capacity and capability in health and social care. She is an appreciative Inquiry practitioner and has experience in human factors. Caroline currently works on Managing Deterioration (ManDetSIP) and Medicines Safety (MedSIP) National Patient Safety Improvement Programmes (NatPatSIP).

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