Title : Risk management and quality of care in drug administration in a critical care setting
Background and Aim:
"Drug prescription and administration is a very articulated and complex process, especially in intensive care and carries with it potential risks of drug administration errors. Risk management assessment is required for procurement, storage, distribution, prescription, administration, preparation, recognition and reconciliation of these drugs.
To Conduct a structured analysis of drug administration in intensive care we aimed at identifying any critical issues, currently existing barriers, areas for improvement and organizational strategies to reduce risks and optimize the outcomes in terms of quality and safety.
A multidisciplinary team was set up that analyzed the pharmacological process in intensive care using the Patient Safety Walkaround and Project management tool. Procedures were revised and new functions were structured for the shared computerised medication chart (e-STU), adding information content tosupport clinical decisions. Warning and alerts using icons have been introduced to draw attention to medical and nursing staff when prescribing and administering drugs with a particular level of risk factors (LASA, HRM) or for reporting allergies. The improvement of traceability on drug management, roles and responsibilities led to just-in-time updating and sharing.
The integrated development of new alert functions for LASA, HRM and any allergies in the computerised medication chart has provided safer management of drug therapy and is in line with Ministerial Recommendations for safety and quality requirements. This tool was presented to the coordinators and health professionals, through information and training sessions. Learning was challenging but it was immediately recognized as an important tool in significantly reducing the potential risks related to the pharmacological therapeutic process.
Preventable adverse events reside in the process of prescribing and administering drug therapy, especially in intensive care settings. Awareness of this risk we aimed at continuous improvement, together with the rational use of resources, this has led to the optimization of the e-STU whilst maintaining even higher standards of quality and safety of care.
Audience Take Away Notes:
• Explain how the audience will be able to use what they learn?
Drug prescription and administration is a very articulated process, especially in a critical setting, and carries with it potential risks of drug administration errors. Risk management assessment is required. For this reason, our project aimed to ensuring continuous improvement of the quality and safety of these processes.
• Does this provide a practical solution to a problem that could simplify or make a designer’s
job more efficient?
Yes, we had re-designing a health tool to assess the quality of care provided and to reduce the potential risks related to the pharmacological therapeutic process: it supports clinical decisions; draws attention to medical and nursing staff when prescribing and administering drugs with a particular level of risk factors (LASA, HRM) or for reporting allergies; improves traceability on drug management, roles and responsibilities. The new shared computerised medication chart is patient based and takes advantage of technology. It also can be used by all providers involved in patients’ care, in all settings. It would be an example for other settings.
• Will it improve the accuracy of a design, or provide new information to assist in a design problem? Yes, because new functions structured for the shared computerised medication chart, based on lean organization principales, would be an example for other settings.