Day 1 :
Keynote Forum
Mukesh Thakur
Professor
Keynote: Internal Medicine and Harm Free Care: A myth or reality
Time : 10:30-11:15
Biography:
Mukesh Thakur is a senior counsultant Internal medicine in Qatar
Abstract:
Background: Patient safety remains a major concern worldwide. Internal medicine patients with multiple comorbidities and fragmented health care utilization are more prone to face adverse events. Patient centered care is now considered as the gold standard to achieve safe and reliable care. There should be ‘no decision about me, without me’. Most organizations across the world struggle to achieve harm free care. One of the robust solutions for this critical problem can be achieved through application of safety culture in the organizations. Α broad range of safety culture is organized into seven subcultures: leadership, teamwork, evidence-based care, communication, learning, just culture, patient-centered care. Method: In our organization, we started implementing safety culture and value based system. We used the IHI (Institute for Healthcare Improvement) model for improvement with rapid cycle PDSA (Plan–Do–Study–Act) change methodology to guide our work. Multidisciplinary teams were involved in this and stakeholders were engaged at all levels. Several initiatives like sepsis bundle, VTE risk assessment, leadership WalkRounds and flow collaborative started at unit level and combined to achieve safety culture in our facility. Results: The initial results are promising. Over the last 15 months leadership WalkRounds implemented in the facility and being conducted three times a month with 100% compliance. Eighty percent of the safety issues raised by frontline staff are resolved within given time frame of two weeks. Surgical site marking increased from 30 to 96% by leadership engagement with multidisciplinary teams. Communications improved with use of ISBAR and compliance is more than 90% among all disciplines. Qatar early warning system (QEWS) was designed to address quick identification of deteriorating patients and implemented with huge success in reduction of number of cardiac arrest calls by 80%. Under flow collaborative, number of patients that left medical unit before 2 pm increased by 75% and 27% reduction in median time from discharge decision to the time patient physically left unit. VTE risk assessment compliance increased to 100% and sustained. Sepsis six bundle compliance is more than 95% in medical wards.
Keynote Forum
Steffi Jerry Mammen
Associate professor
Keynote: A study of medication errors in a multispeciality hospital of Pune
Time : 11:30-12:15
Biography:
Steffi Jerry Mammen completed her Pharm-D in 2014 from Jawaharlal Nehru technological University and is currently pursuing her MHA (Masters of Hospital Administration) from Bharati Vidyapeeth Deemed University, Pune. She is a freelancer, teaching Pharmacology and Pharmacotherapeutics to RMO’s from alternative systems of medicine. She has published various research papers in National and International Journals
Abstract:
Aim: To study medication errors in a multispecialty hospital of Pune Objectives: Identification and analyzing of medication errors during prescription, administration, indenting, & dispensing of drugs. Severity of medication errors analyzed by NCCMERP Methodology: It was conducted in a multispecialty hospital for 3 months dated from 10th Dec18-11th Mar 19. This study is an observational study which includes capturing of data by viewing every 3rd day admission IPD file for prescribing, administration, indenting, and dispensing errors. A pre-designed form was made for collection of these errors by auditing the IPD files in critical units and medical wards. The severity of medication errors was analyzed by using the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) proposed index for categorizing the medication errors. Result: A total of 203 IPD files were randomly taken and audited for medication errors. In that, 50.2%(102) patients showed about 157 medication errors. Out of which 94.9%(149) were actual errors and 5.09%(8) were potential errors. Prescribing errors were found to be 63.05% (99) followed by administration & indenting errors by nurses 22.2%(35) and dispensing & indenting errors by pharmacists 14.60%(23). In prescription error, incomplete prescription written by consultants 39.39%(39) were the most common error reported followed by administration errors, delay in administering stat medications 28.57%(10) was reported. Antimicrobials 76.4%(120) were the common drug class which had a huge number of medication errors. Most of the errors were under the NCCMERP index category B (Error, no harm). No incidence of category I (Error, death) was reported
Keynote Forum
Rubyyat A Hakim
Professor
Keynote: Basildon University Hospital clerking drug history QIP
Biography:
Rubyyat A Hakim is currently working as a Medical Registrar in the Basildon Hospital NHS trust. She is still striving to bring a positive change in patient care every day in the NHS
Abstract:
Aim: The aim of the present study was to find out whether if it was possible to improve the way we document drug history in the hospital clerking proforma during the course of four months period (January-April 2018). Expectation: We had set a goal to have 80% of drug histories in clerking proformas for acute medical admissions filled out correctly by our last cycle of data collection (January-April 2018). Method: Four data collection cycles with 30 patients each were collected (only medical patients). The information we collected was age; day and time patient was clerked (if it was out of hours or not); if the drug history was filled out at all, correctly/incorrectly (compared to the online System One); contributing factors such as diagnosis of dementia, company of relatives and presence of recent discharge summaries. First intervention: inform all clerking doctors via our hospital email. Second intervention: giving a talk to the two groups that clerks the most (Fy2 and CmT) on their teaching sessions. There was opportunity to ask questions and interact. Third intervention: to inform and encourage all clerking medical doctors about the online tool System One. This is currently used by pharmacists and include all current drugs, including what drugs has been dispatched from pharmacy and when. Total improvement: Through our interventions we have made an improvement from 36% to 60% over the four month period. Conclusion: When we analyzed our baseline data collection, we quickly came to the realization that reaching our main goal of 80% correct completion would be very difficult. However, we managed to create an improvement from 36% to 60% from our baseline through our interventions to our last data collection, which we are happy with.