Medication Errors - SWHMC

Sir William Hudson Memorial Centre is a 52 high and 20 low care bed facility located in Cooma on the Southern Highlands of NSW. SWHMC has been benchmarking its key performance indicators with QPS since 2004.

Over the past four years Sir William Hudson Memorial Centre has seen:

• Substantial improvement in resident and employee satisfaction
• Stability in care staff work hours and resident acuity (RCS)
• Skin tears and falls increase and decrease as a result of changing resident conditions and various quality strategies and;
• A decline in staff accidents.

One area of significant effort over the past two years has been in medication management. SWHMC has been successful in getting staff to routinely report medication errors and this enabled their team to analyse that almost all errors (99%) related to missed signings. Achieving long term and sustained success in this area of medication documentation is a fragile process but SWHMC has had some success over the past 12 months. The strategies put in place at SWHMC include:

• The initial step of speaking with the staff and writing to each individual to remind each staff member of their legal responsibilities regarding signing for medications. A significant drop in errors was noted.
• The next step was discussion with staff and a letter of positive reinforcement. A graph showing improvement was attached to this letter.
• An increase in signing errors was detected again in June 2007 and this time the quality improvement strategy was to place large colourful signs saying "have you signed all your medications?" on the work desk and above the medication trolleys. This strategy appears to have worked, as the number of missed signings has continued to drop in recent months even though resident numbers have increased by 20.

Director of Nursing, Deb Wecker is quick to point out that such strategies do not last forever but by continual attention to data collection and prompt feedback to staff SWHMC aims at keeping medication signage omissions and errors to a minimum.