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P-131  Enhancing medicines safety – small changes lead to big improvements!
  1. Kate Marley1,
  2. Carole Slocombe1,
  3. Clare Doyle1 and
  4. Graham Holland2
  1. 1Woodlands Hospice, Liverpool, UK
  2. 2Liverpool Heart and Chest Hospital


Introduction Woodlands Hospice has a transparent approach to incident reporting and staff are encouraged to report near misses. In 2014/15, 76 medicines administration errors were reported, many relating to incomplete documentation. ‘Enhancing medicines safety and reducing documentation errors’ was chosen as an organisational priority for 2015/16.

Actions Improvements were led by the hospice’s Medicines Management Group. A revised medicines management policy was implemented and the annual medicines training programme revised.

Inpatient nurses were consulted for their ideas about improvements in medicines safety and ‘fact-finding’ visits were made to local hospices. All practical ideas were considered and the following were implemented:

  • A ‘Woody’ sign (based on the hospice rabbit mascot) was designed as an aide-memoire to be placed on bedroom doors to indicate that a medicines-related action needs to be completed e.g. return to administer heparin

  • An additional medicine trolley was purchased to reduce the number of patients on each medicine round

  • A Controlled Drug checklist was devised to ensure daily completion of documentation.

Results Medicines administration incidents for the year 2015/16 reduced from 76 to 25.

Additional benefits included:

  • Reduced pressure on nursing staff with more nurses sharing the burden of medicines rounds with round size reducing from 7/8 patients to 5 patients

  • Patients receiving their medicines in a more timely fashion; staff able to spend more time on clinical care

  • ‘Woody’ is a valuable reminder to staff to return to patients if necessary

  • Controlled Drug documentation is checked and completed daily.

Conclusion Focusing on policy implementation and revising medicines training results in a measurable reduction in documentation errors. However, involving a wider team in developing simple, practical ideas leads to improved medicines administration for patients; reduced pressure on nurses; and better staff morale.

Small changes really can lead to big improvements.

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