Service improvement project on increasing information about newly started medicines on discharge paperwork

Quality Improvement Poster Download

Background & Problem

If hospitals fail to share correct information with patients’ General Practitioners about changes to medication, it can potentially increase the risk of the GP prescribing incorrect medication after discharge, with possibly severe adverse impact on patients.

When a patient is eligible for discharge at Gloucester Hospital NHS Trust they are given a prescription called a To Take Out (TTO), listing their medication along with a discharge summary. They are both electronically sent to the patient’s GP. Analysis of patients’ discharge paperwork alongside their inpatient drug chart revealed that medication newly started during admission was the most common change not communicated on discharge paperwork.

Aim

Improve the documentation and communication on the reason/s for starting new medicines on discharge paperwork in 100% of patients by December 2016 on Ryeworth ward at Cheltenham General Hospital.

Method

The project was undertaken on Ryeworth Ward, a General and Old Age Medicine (GOAM). Quality improvement tools were used to analyse the problem and generate ideas for change. Change was introduced via PDSA cycles and the data was collected from the discharge paperwork of patients newly started on a medication and their drug charts.

PDSA Cycle 1 - Handwriting indication for newly prescribed medicine

PDSA Cycle 2 - Sticking a white square sticker next to a newly prescribed medicine. The sticker states: ‘This medicine is newly prescribed for: ‘ (then a space for the pharmacist to write an indication)

Results

Run charts and SPC charts were used to plot the data. PDSA cycle 1 had no effect. PDSA cycle 2 has demonstrated an improvement and data is still being collected.

Further opportunities involve incorporating space on the drug chart for the indication of newly prescribed medicines or using the sticker on a wider scale. Benefits to the sticker include acting as a prompt for the doctors when writing discharge paperwork.