Background Medication errors can lead to patient harm including death. Prescribing error rates of 7% and administration errors of 8% are recognised. Effective systems and processes can minimise the risk of preventable medicine-related problems.

Methods A four monthly audit of prescribing standards contained in the hospice medicine policy was undertaken by the hospice pharmacists. Prescribers received feedback verbally and via posters.

An annual administration of medicines audit was conducted by the practice development nurses. Nurses received feedback and an action plan was agreed.

During the period April 2015 to June 2016, the hospice introduced the Medicine Safety Thermometer (MST) to assess recording of allergy status, pharmacy medicines reconciliation, omitted medicines and safety of high risk medicines.

Results Audit results are displayed in the clinical areas to highlight the current issues. Findings were also used to inform changes in the medicine chart.

An anonymous questionnaire to doctors showed the prescribing audit was felt to be a useful educational tool.

An action from the MST included the development of a variance recording form, integrated in the medicine chart. This records details why a medication was omitted rather than just using a variance code. For example a patient may decline a medicine because they don’t like the taste. The extra detail should trigger an action to resolve the issue.

Implications Prescribing and administration audits and the MST were used in the in-patient hospice environment to identify medicine-related safety incidents. Subsequent learning contributed to the safer use of medicines.