Medicines Management Elmwood and Beechwood wards Parklands Hospital

Introduction • Why – Last summer heat wave, temp above 25 o. C in medicines storage room, led to waste of medicines across the trust – Beechwood/Elmwood chosen as most vigilant in recording incidents • Who are Beechwood and Elmwood – 18 bed wards in Parklands Hospital – Beechwood functional older mental health – Elmwood organic ward

Current state • Heat – Temp graphs • Stock/Ordering – Lack of SOP – B-list – JAC • SLA – Who/what/when – Out of date, not fit for purpose – Remains in draft

Current state: Heat of clinic rooms Beechwood February 2019 28 27 26 25 24 23 22 21 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Temperatures above this line must be reported if more than three times a week or ten times a month.

Current state: Heat of clinic rooms April 2018 -July 2019

Current state: Ordering medications – Well stocked medication cupboards on both wards. – Time it takes to • check stock before ordering • check all medication is in date • go through the B-list – Inconsistences between practitioners – TTO’s and PODs – Doctors reducing medication dosages & nurses driving to pharmacy when short – Medications ‘to follow’. However, other staff when ordering do not refer to the delivery notes and order another batch of meds which is costly. – Controlled Drugs: they can take up to two days to arrive. The book containing CD order/stock information MUST go in a red box as part of the order. It is not good for this to be out of the department for 2 days before the stock arrives.

Current state: The SLA with HHFT • Urgently needs reviewing. Staff have raised this for many years but there has been no ownership or clarity. • Elements of JAC have been removed by HHFT (e. g. labelling) • Causes waste, delays, and frustration, etc • Timely supply is required • 1 – 2 day turnaround for drugs to be delivered. • Urgent CDs require an emergency prescription to be created to enable same-day supply. • Overall there is frustration due to apparent lack of progress with reviewing current SLA. There is a lack of co-ordination around: • Stock supply issues • Timely delivery

Outcome of RPIW • Ideas and themes

Outcome of RPIW • Generation of themes – Waste – Supply/Stock – IT – Training – Staff well being – SLA – Communication – Prescriptions

Staff Well-Being and waste of medicines • RPIW – Came here to discuss excessive heat in clinic rooms affecting meds, however we recognised the greater impact this had on staff – Driver diagram – Met with estates

Staff Well-Being and waste of medicines • 30 days – Estates fix airflow (or work out what needs fixing – capital bid if required) – Change fluorescent lights to LEDs – Keep monitoring temps • 60 days – Has anything changed? • If required – stable door • Still hot – air conditioning • 90 days – Update on data – is this working?

Stock • RPIW – Reduced B-List (draft) – Created SOP for the wards • Flow chart created – Medicines Administration Technician role • Enhance stock/supply efficiency, less waste, reduction of poor supply, release of nursing time • Challenge with recruitment

164

85

Stock • 30 days Reduce duplication in clinic cupboards Reduce the hard copy of B-List (Sunday) Send list to Pharmacy to update Train colleagues on the new SOP (Friday 20 th) Also – See One, Do One, Teach One. – Create in-depth SOP for front of file – Flow chart to go in clinic room cupboard – Lead Tech present plan for MAT or SATO to Chief Pharmacist – – • comprehensive feedback to teams • 60 and 90 days – PDSA with stock/supply/B-list – PDSA SOP – Review outcome of MAT/SATO

SLA/Meds Policy • RPIW – Does the SLA work? • Should reflect how it needs to be used on the front line, therefore devised with frontline members of staff – We don’t use on-call pharmacy • Reinforce the use of on-call pharmacy- immediately – Medicines policy two hour window for drugs administration • This is a myth, we will now manage administration as per patient needs, chief pharmacist informed

SLA/Meds Policy • 30 days – If use of on call is not successful escalate to Chief Pharmacist/Ulysses – Identify the parts of the SLA that are not working • 60 days – Further action amendment to SLA how to manage meds out of hours • 90 days – PDSA

JAC (e-prescribing system) • RPIW – Lack of training leading to • • inconsistent use mistakes, wasted time/medication, inability to admit patient to ward due to function errors – Are we not using full capacity of programme, do we not understand programme, what happened to the role of JAC champion • Immediate action- contacted HHFT for help and further training

JAC (e-prescribing system) • 30 days – Parklands MMT will speak to other HHFT Pharmacy Team for their perspective on use of JAC and wards using this programme well – Review implementation of JAC champion • 60 days – Nurses booked to attend HETT show where JAC developers will be to question around programme functions, identify centre of excellence where we can shadow and question – Feedback findings • 90 days – Continued review to ensure reduced wasted time, ease of admitting patients, improved staff capability and understanding

TTO/Labelling • RPIW – Two causes of medicines waste identified on the wards • Duplication of TTOs • last minute necessary changes to medication requiring further drug supply – Re-Labelling function on JAC was removed by HHFT with no staff consultation • Labelling allows adjustment to dispensed medication and reduces waste, and enables timely discharges if any last minute changes are required • Reduces risk of patients being discharged, or going on leave, with incorrect meds

TTO/Labelling

TTO/Labelling • 30 days – SHFT asks HHFT to reinstate the labelling function – Parklands MMT to contact other team members who may have alternative labelling programme, investigate other options – Reiteration of request for Pharmacy to be part of the MDT • Timely discharges, reduced poly-pharmacy issues, improve patient care, • reduce duplication of TTO ordering by potential recruitment of a MAT/SATO • 60 days – Evaluate impact of above actions • 90 days – Roll out changes, share with other departments

We need…. . • Commitment to exploration of MAT for Beechwood and Elmwood, a clear outcome and action plan within 90 days • Authority to explore JAC • Supernumerary status (one day a week for two months) to maintain momentum – Safer staffing team and senior leadership to support the process • All involved in the week to do what they said they would

Lessons learnt…. • Utilising the QI skills we learned this week, we will go back and review current tasks and ensure they add value • Staff involved needed more time to consider and understand the project, they could have then invited further people with breadth and depth of representation • QI facilitators have learned to take more ownership of the communication process, involve the staff on the ground more and not rely on their management • We would like the QI team to enable services within the Trust to come forth with their needs for QI, not have QI parachuted upon them, also ensure staff are aware QI exists and know the pathways to contact QI and become involved