Transcript Chance to Check initiative

Chance to Check
Karon Cormack
Clinical Risk Manager
Greater Glasgow & Clyde Health Board
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Medication incidents
Interested in wrong patient incidents
Violation of policy
Theory regarding the reasons
SPSP work – deliberate design vs
hard work and vigilance
 Chance to check concept
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Focus Groups
Medication errors and practice:
 5 groups between 6 – 24 (12 ideal)
 Hardly any had been involved in a focus
group before
 Wary at first but soon talked freely
 Debated with each other
 Needed to be controlled without influencing
 Rich source of information
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Focus Groups - medication round
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Not enough time
Debate about who should do it
Lost importance
Feels very task driven
Underlying concern
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Focus Groups – current practice
 Admitted to not checking name band
 Admitted giving drug they are not
sure of
 Admitted not thinking about the
patient in relation to the drug
 Admitted problems with no
interruptions
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Focus Groups – name band
 Feel they know the patient
 Embarrassment - as if nurse has
forgotten who the patient is
 Don’t want to disturb patient e.g. at
night
 Time
 Felt to be different from blood
transfusion
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Chance to Check - content
 Identifying 4 key statements that
must be self asked on each
administration
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Chance to Check 1.
 I know
I think this when
what this I am dispensing
drug is
the drug into the
medicine cup.
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Chance to Check 2.
 This drug
and dose
is suitable
for this
patient
I think this when I
have dispensed the
medication and I
am thinking of the
patient I plan to
give it to.
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Chance to Check 3.
 The
patient
verbally
confirms
their name
if possible
On approach to
the patient I ask
for confirmation
of name.
“Hi Mr Brown, I have your
medicines, tell me your
full name please”
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Chance to Check 4.
 The
patient's
name band
matches
the kardex
I check the
patient’s name
band with the
name and DOB
or CHI number
on the kardex.
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Chance to Check - content
 Identifying 4 key statements that
must be self asked on each
administration
 Prompt cards can be used initially but
should become automatic.
 Every patient, every time deliberate
design.
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Chance to Check – time / focus
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Take the time to get the task right
Do the right checks
Acts like a pause in the process
Raise awareness of medication issues
Prompt ward discussion
Standardising approach
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Additional Points – No interruptions
Signage
On admission
Communication book
Agreement on acceptable
interruptions
 Be strong and united
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Additional Points - BNF
 One on each trolley
 Up to date
 Labelled
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Post Round Sweep
Reduce errors relating to medicines;
 Omitted / forgotten / lost
 Taken late
 Taken by other patients
Your drug round – your responsibility.
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Promote ward discussion
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When & Who?
Incidents feedback
Review Chance to Check
Praise
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Implementation
 Pilot wards
 Spread to other wards in S&A
 Taken to Heads of Nursing and spread
to other directorates
 Included in MyMeds project
 Recently introduced to 3rd year
undergraduates
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Results
 Staff like it
 Feel they have permission to do the
right thing
 Feel they are using nursing
knowledge
 Feel more assured the process is
good
 Less interruptions
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Any Questions?
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