Medication Errors; Improvements in Ross Home Presbyterian Support Otago Dunedin

Medication Error Reduction

Ross Home is situated in Dunedin's North East Valley, New Zealand and is renowned for its stunning gardens and courtyards, personal care approach and has a long, proud tradition of providing quality services.

A seamless and efficient process was one focus

Ross Home has a long history of maintaining exceptional standards in the safe delivery of medication to their residents, and these results continue to be sustained and are evident in our QPS benchmarking reports. We began a systems wide quality improvement activity in 2015, to look at our medication charting, dispensing and administration processes to decrease the risk of medication errors. Our initial research included the requirements for staff, General Practitioners and our pharmacy supplier and the use of various electronic medication systems took place. The focus was also to ensure the process from charting through to administration was seamless and more efficient. An electronic system was introduced into Ross Home late 2015 following initial staff training. Once our staff, GP’s and our pharmacy became more familiar with the system, further efficiencies were gained by providing our primary GP with access to the system from home. This improvement allows us to make medication changes out of hours immediately, and has minimised the need for verbal orders. The electronic system itself does not allow staff to close out of a resident’s screen if they have not signed off administration for every medication. It also alerts staff if there are any Short Course medications to check.

Internal process improvements were also introduced such as affixing bright red signs to the side of the medication trolleys to inform staff and visitors “Not to disturb the Nurses during Medication Round” unless it is an emergency. Ongoing training sessions are held on medication packs and safe administration for all medication competent staff.

Jenny Jackson, Unit Nurse Manager, Ross Home Presbyterian Support Otago Dunedin