Introduction The NICE quality standards for care of adults in the last hours/days of life state that all patients should have appropriate as required medication (PRN) prescribed for the symptoms (pain/breathlessness, agitation, nausea/vomiting and respiratory secretions) that can occur at the end of life (EoL). This quality improvement project tested the adherence to this in one UK district general hospital.
Aims To investigate whether PRN anticipatory medications were prescribed in accordance to trust guidelines to inform future quality improvement work.
Method This was a prospective audit of 20 consecutive patients across adult wards in June 2018. Drug charts were audited using a tool based on the trust guideline, and the auditor met with junior doctors to discuss concerns around prescribing.
Results 25% (n=5) of prescriptions were accurately compliant with guidelines. In medications for pain relief and agitation drug dose was correct in 75% (14) and 60% (12) respectively, however dose frequency was incorrect in 45% (9) and 70% (14), with too long a dose interval in 40% (8) and 50% (10) respectively. The PRN medication with the most errors were medication for nausea/vomiting and respiratory secretions with the dose missing or incorrect (no maximum 24 hour dose recommendation) in 95% (19) and 80% (16) respectively. Discussion with junior doctors highlighted a lack of awareness of the guidelines.
Conclusions Despite the existence of trust guidelines prescription errors for anticipatory medication at EoL were common. The main concern being patients may have symptoms under treated due missing drugs or too long dose frequency. In collaboration with the specialist palliative care team, pharmacy and junior doctors a poster was created and displayed across all wards. This was supported by teaching sessions delivered by a junior doctor to junior doctors to promote the content of the poster. The adherence to guidelines will be re-audited in 2019 and included in the presentation.
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