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Quality Improvement Task for Patient Prescription Record

The goal of this quality improvement task is to ensure that nurses record in the selected container on patients Prescription and administration record (to be known as: Kardex) if High Medication dosage Antipsychotics Monitoring does apply YES or NO (to be referenced as: suitable Y/N) and consequently if yes, that the High Medication dosage Antipsychotic Remedy monitoring form (to be known as: Monitoring form and the Early Warning Signs (EWS) Form have been triggered for completion. The goal of this is to secure patient safety from the side ramifications of the medication.

There is widespread evidence which clearly links back to you antipsychotic medication contributing to physical health problems such as cardiovascular problems, weight gain, endocrine problems, metabolic syndrome and sudden death (Gumber et al, 2010; Churchword et al, 2009; Tyson et al, 1999). Many early deaths of folks with serious mental disease are anticipated to poor medical care that does not keep an eye on risk factors which might be due to side effects of medication (Cohen & Hove, 2001). A council article by the Royal University of Psychiatrists (2006) uncovered that past audits of high medication dosage antipsychotic prescribing for in- patients revealed poor adherence to monitoring recommendations. All patients on high medication dosage antipsychotic treatment must be supervised. These guidelines attempt to clarify the identification of patients on high dose antipsychotics, factors to be studied into consideration before such prescribing and the records required when antipsychotics are recommended in high medication dosage; furthermore it is a policy dependence on Forth Valley that records is completed for these patients (Forth Valley, 2011).

The demand nurse highlighted a concern when analyzing the patients Kardex audit, it exhibited 100% non-compliance for the conclusion of the Yes/No response for high dose antipsychotics monitoring. Subsequently when the patients are obtaining high medication dosage antipsychotics, there is inconsistency of the completion of the treatment monitoring form and EWS form. A recent audit of patient Kardexes proved the charges nurse finding (see Pareto chart, Appendix B).

To begin the procedure of the product quality improvement project, a general ward meeting was held and went to by all staff in the ward that was on change. During the assembly the fee nurse highlighted the recent conclusions of the Kardex audit. Concerns were elevated that lots of areas on the Kardex were not being completed, and reminded personnel nurses that this is not acceptable and needs to be improved. As a nurse it is extremely important to keep correct documentation, good record keeping is an fundamental part of medical practice, and is necessary to the delivery of safe and effective care (Nursing and Midwifery Council, (NMC) 2010).

As an attempt to focus the quality improvement project more specifically the results of the audit were provided by using a Pareto chart (Appendix B). The info verified the areas on the Kardex which were not being completed however, high medication dosage antipsychotic monitoring Yes/No was the best at 100% non-completion, therefore it was agreed a new strategy would be applied to improve this. McLaughlin and Kaluzny (2006) state that the defect focused on does not automatically need to be the greatest frequency to be improved first, but attention should be given to that defect which may have a damaging end result, such as an adverse event or even fatality. Nevertheless the defect in this situation was the highest and potentially could cause an adverse event.

Following the meeting a questionnaire (Appendix C) was devised and completed anonymously by the pharmacists, consultants and personnel nurses to identify the root factors behind why this area on the Kardex was not completed. A fishbone diagram was used to demonstrate the conclusions (Appendix D). When populating the fishbone diagram with the data, it was obvious to see that there have been many reasons that every person in the multidisciplinary team hadn't completed the appropriate area on the Kardex. Role confusion was a common theme from each member of the team. Hill-Smith et al (2012) promises that is not different within multi-disciplinary teams and this respectful communication and clear instructions is of high importance in the delivery of high quality scientific care. Therefore predicated on these conclusions PDSA one was developed (Appendix G1). This examined if the nurse participating in the MDT meeting completes the Suitable Y/N on the patients' Kardex following an email reminder and a verbal prompt from demand nurse before participating the reaching. The test confirmed there is a breakdown in communication, the nurse didn't have the email or a verbal reminder from the demand nurse prior to attending the MDT assembly therefore they were not aware of the task that had been discussed and as a consequence the relevant area on the proper execution was not completed, this is verified by an audit of the Kardex (Appendix H). This enlightened your choice for PDSA two (Appendix G2). The nurse coordinating the move should use the visible fast situated on the move coordinating sheet to remind the nurse joining the MDT conference, to update relevant Y/N on the patients Kardex. The tiny change of an visible reminder on the change coordinating sheet proved to be success. It reminded the coordinating nurse to verbally prompt the nurse participating the MDT appointment to complete the patient's Kardex in the appropriate area, that was shown by the Kardex audit following the shift; all patients' Kardexes were completed and as a consequently the Therapy form and EWS from were also initiated for completion. These conclusions are steady with Simpson (2007) research, where groups have clear operating procedures in place, attention coordinating is improved.

The assumption was that the email and verbally prompt from the fee nurse would result in nurses concluding the Relevant Y/N on all patients Kardexes, following a MDT assembly by 23rd Feb 2014 by 100%. Furthermore, if yes the Therapy form and the EWS form turned on for completion.

Audits were completed on the dates shown to give a snapshot of the completion of Applicable Y/N on all patients Kardexes in the IPCU ward at that time. Initial results of the first audit by the demand nurse on 01/02/2014 disclosed that Applicable Y/N was completed 0%. The next audit carried out to confirm the prior results on 08/02/2014 which established the demand nurses results of 0% conformity of Applicable Y/N. PDSA one was carried out on 10/2/2014 the change unveiled 0% improvement in the completion of Applicable Y/N. PDSA two was carried out on 21/2/2014 the change was successful, the results of the audit exposed that Applicable Y/N was completed on all patients Kardexes by 100% therefore activated the conclusion of the treatment form and EWS Form.

Comparison of questions, predictions, and evaluation of data:

Engaging with the quality improvement (QI) project has required me to learn and apply new skills used.

The process of plan, do, analyze, work (PDSA) cycles were a new technical skill which I had never to only learn myself, but train fellow personnel nurses on the ward, as this is also, a new process to them. I learnt that PDSA cycles provisionally test an idea by testing a change and examining its impact. After implementing the first circuit, I learnt that it generally does not always have the results expected when coming up with changes to your process; it trained me that it was better, and more effective to trial a tiny change to find out if it made a notable difference, before applying the change entirely. This also gave personnel the opportunity to be involved and provide suggestions and see if the proposed changes works.

I also learned that communication is an essential and important process during the QI. Relating to Adams (1999), to persuade others to make a noticable difference or change, the negotiator must be influential. The Demand nurse in this situation was the important position to lead change. Unfortunately they were unable to fulfil their responsibility in PDSA one, nonetheless they carried out the ward reaching and used this as a platform to discuss the Kardex audits with the staff which enlightened them of the need to make a noticable difference in practice. After the need for the new process was set up and its concepts by the e-mail from the charge nurse, informing the reasoning for a change in practice, this is used as basics for PDSA two. I learnt that it is merely as important to explain the chance of not making an alteration (Plummer, 2000) and in this situation, changing practice would not only improve quality of care to patients, but it could promote the involvement between staff nurses and the MDT, building trust and confidence to help make the change, whereas the chance of not making the change, may potentially cause a detrimental event

A final learning point I would like to add was how personnel nurses primarily were resistant to change. In my opinion from observing, the nurses were quite defensive as though they were being blamed for not doing their job properly. The questionnaire used was an efficient communication tool and successful learning resource for controlling this level of resistance. It give personnel the chance to anonymously responses their reasons for not concluding the appropriate area on the Kardex, it also let them express their opinion without having to be condemned. Also, Personally i think that during this time, they were in a position to adjust and prepare for the change which minimised resistance (Bernhard and Walsh, 1995). I noticed it was essential to observe all their views as individuals and as team members, which provided further justification with their reasoning for non-completion. Accountability was a steady reason employed by nurses for their reason for non-completion, as they sensed it was a health care provider or the pharmacist role plus they did not desire to be accountable for making the decision. When it was clarified that it was a team decision, by email from the demand nurse, the nursing staff felt backed. Mitchell (2001) claims that accountability in nursing is a sophisticated issue and acknowledged the value of team support in the identification of roles and responsibilities. Frequent ideas and discussions with staff were held in the ten days, before the change in PDSA two that i feel made the improvement successful and run smoother as medical staff were alert to the new change.

I have learned that within medical it's important to continually improve the way we work. Working at every level expanding the knowledge, technological skills, including command, are essential for long-term improvement. Continually learning may make a difference not only to ensure that people have the skills needed to increase the quality of medical care, but also to improve the motivation to take action.

Discuss the project's significance on the neighborhood system and any studies which may be generalizable to other systems:

Relocation to a new site change what been good practice and today a gap experienced appeared in the process of monitoring patient.

The outcome of the project was a success. It was predicted that by 23rd Feb 2014 suitable Y/N would be completed by 100%. By creating the success of the visual fast in PDSA two on the co-ordinating sheet, was a very small but effective change.

As a consequence, at the following staff reaching it was chose that the aesthetic prompt would be a long lasting fixture on the coordinating sheet, as it was a sustainable reminder to future change coordinators, thus bettering the initiation of remedy monitoring and EWS varieties, and overall patient security outcomes.

Discuss the factors that promoted the success of the project and that were barriers to success. What do you learn from doing this project? What are your reflections on the role of the team?

The factors which advertised success in the project were support and leadership from the charge nurse at the start of my positioning. They helped identify areas in the ward that they thought needed improvement. Furthermore, as students who had never experienced a mental health ward, I believed overwhelmed with the duty which support and information helped me through the task.

The use of the various tools were a terrific way to involve personnel on the ward to feel a part of the project and broke down the obstacles of pointing blame and focussed their attention in a systematic way, and explored the potential causes of the non-completions.

I was impressed as how such a little change help facilitate and test change in a manageable way. I now understand that Quality improvement as a means of approaching change in medical care that focuses on self-reflection, examining needs and gaps, and considering how to boost in a multifaceted manner. Personally i think I've gained an enormous understanding in about quality improvement in that it aims to create an ethos of constant reflection and a commitment to ongoing improvement. It offers nurses to gain an the abilities and knowledge needed to assess the performance of medical care and specific and populace needs, to comprehend the spaces between current activities and best practice and have the tools and confidence to build up activities to reduce these gaps

Thus, the scan did not concentrate only on narrowly described quality improvement models such as 'plan, do, review, action' (PDSA) cycles.

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