Nursing Unit

Hospital Raja Permaisuri Bainun Ipoh

 Presentation Outline

Introduction

Background & Problem Literature

Methodology
Statement Review

Result Discussion Recommendation Conclusion

 Introduction
Introduction & Background
• 4 cycles of prospective clinical audit related to shift handover
procedure and medication error study.
• Shift handover procedure is the outgoing nurses discuss with the
oncoming nurses the condition of each patient and any changes
that have occurred to the patient during the shift (Groves et al
2016).
• Defined by the National Coordinating Council for Medication Error
Reporting and prevention (2007), medication Error is
• ‘‘Any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the
control of health care professional, patient, or consumer. ”
• The importance of nurses roles and responsibilities is to ensure
Medication safety.
 Problem statement
• The 13 Malaysian Patient Safety Goals (2015) no. 7 is to ensure
Medication safety.
• Malaysian Nursing Division has initial National Nursing Audit as a
yearly essential audit on oral medication procedure to sustain and
reduce medication error since 2005.
• There were 8 incidences of medication error (nm/r) in HRPB which
involved nurses related to missed or ineffective communication
during handover from 2015 to 2016.
• The nurses to nurse’s handover are not taught formally during
nursing training, yet it is one of the most important rituals of the
nursing shift.
• We identified that the variation of SOP failed to communicate and
check medication before serving to the patient as well as failed to
check during shift handover procedure are the main weaknesses
contributing to Medication Error after RCA.
 Literature Review
• Joint Commission’s 2006 National Patient Safety Goal 2:
Improve Staff Communication and Goal 3: Improve the Safety
of Using Medication emphasized that the importance of
communication between the healthcare staff to ensure
medication safety.
• Hansten(2003), the primary goal of shift handover is to
communicate the patients’ clinical information and to provide
a safe and high-quality care.
• Lally (1999), evidence shows that effective shift handover
decreases the risk of medication error and sentinel events,
delays the course of treatment, decreases patient satisfaction,
and prolongs the length of hospital stay.
 Objective of study

• To Reduce the Incidence of Medication Error by

Counter Checking the Medication Prescriptions
and Medication-related Nursing Documentation
by Nurses During the Procedure of Shift
Handover
 Specific Objective:

• To observe the compliance of medication prescriptions

were counter checked by nurses during the procedure
of Shift Handover.
• To observe the compliance of all medication-related
nursing documentation been counter checked by
Nurses during shift handover.
• To observe the compliance of all prescribed medications
as in medication chart been signed by Nurses as evident
after served.
• To monitor and record the incidence of medication
error prospectively.
 Clinical Audit – Criteria & Standard
Criteria Standard
All medication prescription were counter 100% of medication prescriptions were
checked by Staff Nurses for Right counter checked by nurses during the
procedure of Shift Handover.
Prescription during the process of Shift
Handover.
All medication-related nursing 85% medication-related nursing
documentation has been counter check documentation were counter checked by
by Staff Nurses during the process of Staff Nurses during the procedure of Shift
Shift Handover. Handover.

All medications chart has been counter 100% medications chart were counter
check for the evidence of medications checked for the evidence of medications
been served (signature) by nurses. been served (signature) by nurses.

Outcome Zero Medication Error related to invalid

Number of Medication error recorded & prescription and failure to communicate.
reported (prospectively)
 Methodology
Over View & Study Part I is an observational clinical audit by using a
Design standardized checklist to measure the compliance of nurses
during the procedure of shift handover.
Part II is to monitor and record all medication error
prospectively
Location Medical/Surgical/Orthopedic / O&G wards

Population All Nurses in the selected wards

Sample and sampling 8 sections of shift handovers randomly selected from each
ward (location) for each cycle
Auditors Repeated training require before each audit cycle
Period of audit 2 weeks
Inclusion Criteria Sections of shift handovers included 3 shifts AM/PM/ON

Exclusion Criteria none

 Definition of Variables
Variables Operational Definition
Medication Any preventable event that may cause or lead to inappropriate
Error medication use or patient harm while the medication is in the control of
health care professional, patient, or consumer.
Shift Handover is a communication that occurs between two shifts of nurses whereby
the specific purpose is to communicate information about patients under
the care of nurses.
Whereby the process of transferring primary authority and responsibility
for providing clinical care to a patient from one departing caregiver to on
oncoming caregiver.
Medication & Documents include :
Nursing care Inpatient Medical Record, Medication chart, Nursing assessment chart,
related Nursing Care plan, Nurse Observation Chart and Intake output chart.
document
Inpatient Chart for the prescriber to prescribe medication for the inpatient in the
Prescription ward. Nurses will send this char to the pharmacy department to indent
Chart the required medication as prescribed.
Nurses Trained Registered Staff Nurses Grade U41 and U29/U32
Part 1 : Clinical Audit Checklist- Checklist NCA/HRPB/CL-01
Measurement ( √ )
S/N Statement
Yes No NA
1. Shift Handover on time
2. Handover and counter check patient condition bed to
bed between the staff of both shifts.
3. Did the staff communicate with the patient?
4.1 Handover and counter check current and update
contents of patient’s nursing documentation included:
Nursing Assessment – the patient’s condition should
coherence to prescribed medication.
4.2 Nursing care plan (NCP)
(Check related prescribed medications as intervention
according to patient’s condition)
4.3 Nursing reports related to the implementation of
intervention and evaluation (especially related to
prescribed medications) in NCP.
Part 1 : Clinical Audit Checklist- Checklist NCA/HRPB/CL-01 –cont’
Measurement ( √ )
S/N Statement
Yes No NA
5. Patients care associated charts:
Temperature chart (may related to anti-pyrexia/antibiotic/side
5.1
effect)
5.2 Vital sign (may be related to almost all drug and side effect)
Pain Score assessment (may be related to before and after an
5.3
analgesic)
5.4 Intake /Output chart (may related to diuretic or others)
Each prescription in medication chart is correctly prescribed as
6.
recorded accordingly in the patient’s clinical notes.
Each prescribed medications in drug chart were signed for served by
7.
SN.
Any un-signed column should be confronted by both shift’s RNs and
8.
reported to superior immediately.
Any query related to prescribed medications should be clarified
9.
between the 2 shift staff immediately
 Ethical Considerations
• This study obtained approval from the Hospital Director and
Chief Matron.
• Registered to National Medical Research Registry (NMRR)
prior to conducting the study
– (NMRR-16-836-30770(IIR)
• And this project was approved by MREC to collect data from
KKM setting- HRPB
• All the information enrolled by participants were kept
confidential.
 Data Processing And Analysis

• The collected data processed and analyzed by

means of descriptive measures using the statistical
package for the social sciences (SPSS).
• The total and frequency (in percentage) method will
be used to analyze the result in part I and part II.
• The summarized data will be presented in form of
graphics and tables accordingly.
 Methodology Flow Chart
Clinical Audit decision made as QIP of Nursing Unit HRPB

Formation the Audit Committee

Topic and Area of Clinical Audit been identified

Project proposal agreed by Hospital Director and registered to NMRR

Training the auditors

Group of Nurses Monitor & Record of

Medication Error
Checklist 1 Analysis by SPSS
descriptive

Reporting
 Gantt Chart of Project Clinical Audit 1st Cycle
Project weeks Apr to Jul 2016
Clinical Audit
S/N April 16 May 16 Jun 16 Jul 16
Activities
1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th
Group Formation &
1. X
Choose topic
Agree/Review
Standards and
2. X X X
completed Proposal
for approval
Collect Data On
3. X X
Current Practice
Analyses Data And
4. Compare Data With X
Standards
Discuss Finding &
5. Reliable Improvement X X
Action
Planning For Agreed
6. X
Change /Intervention
Implementation
7. /Assisted & X X X X X
Monitoring
Re-audit After 3
8. X
Months
9. Report & Presentation X X
 Summary of The Audit Cycle
Cycle Ward involved sample Period Improvement Set Standard
1st General Medical May 2016 as proposal 100%of medication prescriptions
Ward only –(n=56) and nursing care related documents
were been counter checked by
nurses during the procedure of Shift
Handover.
2nd General Medical / Aug 2016 Amendment 1.100% of medication prescriptions
Surgical Wards - to the were counter checked by nurses
(n=57) Checklist during the procedure of Shift
Handover.
3rd General Medical / Aug 2017 Amendments 2.85% medication-related nursing
surgical/orthopedic to the documentation were counter
Wards (n=104) Checklist checked by Nurses during the
procedure of Shift Handover.
3. 100% medications chart were
4th General Aug 2018 - counter checked for the evident
Medical/Surgical/ been served (signature) by nurses.
Orthopedic /O&G 4. Zero Medication Error related to
Ward (n=151) invalid prescription and failure to
communicate.
 General Observation Result

Part 1: Observation clinical audit

Achievement /compliance %
S/N Statement 1st cycle 2nd cycle 3rd cycle 4th cycle
n=56 n=57 n= 104 n=151
1. Shift Handover on time 98 100 98 100
2. Shift Handover process
75 98 98 98.7
bed to bed
3. Nurses communicated
- - 60.2 66.2
with patients

At the 4th cycle, 100% of shift handover happen on time between the two shift
with 98.7% were occur bed to bed.
However, there was only 66.2% of nurses communicated with patients.
 Part I Audit Result
Compliances to Standard

100.0% 95.2% 95.2% 95.4%

89.3% 90.1%
90.0% 84.5%
87.0%
80.0%
67.3% 74.9% Standard 1
70.0% 64.3%
64.3% Standard 2
60.0% Standard 3
50.0%
43.9%
40.0%

30.0%
1st Cycle 2nd Cycle 3rd Cycle 4th Cyele

Standard 1 = 100% of medication prescriptions were counter checked

Standard 2 = 85% of medication-related nursing documentation were counter checked
Standard 3 = 100% medications chart were counter checked for the evidence of
medications been served
 Clarification when any ambiguity or unsigned
40.0%
33.5%
35.0% 32.1% 31.0%
29.5%
30.0%

25.0%

20.0%
16.1% 15.7% 14.6%
15.0%
10.5%
10.0%

5.0%

0.0%
1st Cycle 2nd Cycle 3rd Cycle 4th Cycle

Unsigned Column Ambiguity

There is an average about 14.2% of the unsigned column and 31.5% of

the ambiguity were been clarified during the shirt handover report
shown in all the 4 audit cycles.
 Part II Audit Result

Compliance to Standard 4
Zero Incidence of medication error

From Jul 2016 until 31 Aug 2018. There is Zero Medication

Error reported in HRPB related to medication prescriptions
or missed communication during shift handover .
 Discussion
• Awareness to all nurses counter checking is essential
during each shift handover

• Amendments of the audit checklist and training for all

staff including auditors as required.
• Better communication with other profession such as
Medical Officer and pharmacist could reduce ambiguity.
• Communication between nurses with patients is another
important issue need to be improved as included in 3rd &
4th cycles of audit.
 Action plan
Possible barriers
Responsible
Recommendation Action Required to Timescale
person
implementation

Standardized of the process Higher Nursing Syllabus added/

and content of Shift Authority/ require extra Top
-
Handover in Basic Nursing Nursing credit hours Management
Training program Institution
Enhance communication Nursing knowledge
6-12
between patient and staff in Management attitude PJ & KJ
months
the wards Skill
Extend the clinical audit to knowledge
Nursing 6-12
all the wards as yearly event attitude PJ & KJ
Management months
prospectively Skill
Fine improvement on the knowledge
Audit leader & 2-4
Checklists are required for Experience Audit team
team weeks
better understanding Skill
knowledge
Retrain and recruit new Audit leader & 3-6
Experience Audit team
auditors are essential team months
Skill
 Conclusion

• The compliance to standard of clinical nursing audit shown:

• Effective shift handover with proper counter checking the
medication prescriptions and medication-related nursing
documentation by nurses has significantly decreased the risk
of medication error and sustained medication safety as the
result shown zero incidence of medication error after
implementation of the project.
• However further knowledge development of the handover
procedure is required for betterment.
 Acknowledgement
Grateful to the Hospital Director and the Chief
Matron and Matron Committee of HRPB who’s
been generous and supportive for me to complete
this study.

Appreciation is given to Nursing Sisters and all

nurses who involved in the Clinical Audit for their
kind attention, commitment and participation.
A big thank you to our patients who committed to
our audit and nursing care.
 References
• Groves, P. S., Manges, K. A., & Scott-Cawiezell, J. (2016). Clinical
Nursing Research. Handing Off Safety at the Bedside .
• Hansten, R. (2003). Notes from the field. Streamline change-of-shift
report. Nursing Management. Aug; 34 (8): 58-59.
• Lally, S. (1999). An investigation into the functions of nurses’
communication at the inter-shift handover. Journal of Nursing
Management, 7, 29-36.
• National Coordinating Council for Medication Error Reporting and
prevention (2007)
• The Joint Commission’s 2006 National Patient Safety Goal
• The 13 Malaysian Patient Safety Goals (2015) Nursing Division
• World Health Organization (2007). Communication during patient
hand-overs. Patient Safety Solutions, 1(3). Accessed from
http//www.who.int/patientsafety (26 May, 2008).