QUALITY IMPROVEMENT PROGRAM

ON
IMPROVEMENT OF LEGIBILITY AND APPROPRIATENESS
OF MEDICATION ORDERS IN PATIENT RECORD
Programme Members

Staff Nurse –Nursing Quality Dept.Medication

safety nurse
Quality executive

Guide:– Medical Director

Facilitators: Nursing Director

 AIM
To minimize Incidence of the following in Medication
chart/Progress notes

1. Generic name not written

2. Medication orders not written in CAPS
3. Wrong route
4. Wrong Dosage
5. Wrong drug
6. Wrong Freq
7. Illegible writing
8. Medication orders stopped improperly
9. Name and signature of the prescribing authority
OBJECTIVE
At the end of Study

 Doctors are able to prescribe legibly in Medication Administration chart.

 Medication orders are written in generic name with proper route, dosage and
frequency
 Every Medication orders are Named, timed and signed
 Duty medical officers have adequate knowledge about brand and generic
name of drugs.
 Increased reporting of medication errors
 Input
 Policy on Prescription writing
 Policy on Verbal orders
 Continuous Training for Nurses on Medication
orders
 Daily Checking of patient Orders by Staff
Nurse-Nursing quality Department
• Medical Director meeting the consultants
about ILLEGIBLE WRITING.
Data collection Method
• Medication Administration chart Checked.

• Physician orders checked.

Sampling

• Random Convenient sampling

Sample Size

• 75 per week
Duration of study
One month (December)
 Reporting form for QIP –Medication chart illegibility

Wrong Wrong Wrong Brand Discontinu Medication general Medication Medication Medication Lack of
route Dose frequen name ation order names Not illegibility of orders not orders not orders not signature after
cy written for drug written in medication named(Progr Timed(Progr Signed(Progr medication
improper CAPS order ess notes) ess notes) ess notes) administration

1st week 1 0 0 40 23 5 27 9 16 10 15

2nd week 0 1 0 32 24 3 22 7 14 7 13

3rd week 0 0 1 36 16 3 18 7 15 6 10

4rth week 0 0 0 28 10 2 15 6 12 7 6
 FINDINGS

 Reduction of “Wrong route” was observed to be 100 %(1-0)

 Reduction of “Wrong dose” was observed to be 100 % (0-1-0)
 Reduction of “Wrong Frequency” was observed to be 100 %(0-1-0)
 Reduction of “Brand name written ” was observed to be 30 %(40-28)
 Reduction of “Improper Drug discontinuation order ” was observed to be
56.5 %(23-10)
 Reduction of “Medication orders not in CAPS ” was observed to be 40 %(5-2)
 Reduction of “General illegibility” was observed to be 44.4 % (27-15)
 Reduction of “Orders not named” was observed to be 33.3 % (9-3)
 Reduction of “Orders not timed” was observed to be 25% (16-12)
 Reduction of “medication orders not signed” to be 30% (10-7)
 Reduction of “Lack of signature after medication administration” 60%(15-6)
 Recommendation
1. Nurses training on medication orders needs to be strengthened
2. Doctors training and Compliance monitoring towards writing medication orders in
brand name needs to be strengthened
3. Signing, Naming and timing of medication orders needs to be strengthened
 QIP on Reduction of
Patient Fall Incidence
Programme Members

Staff Nurse –Nursing Quality Dept.Patiemt

safety nurse
Quality executive

Guide:– Medical Director

Facilitators: Nursing Director

Aim
To reduce the incidence of patient falls in hospital by
more than 50 percentage
To Eliminate incidence of falls in Neuro Ward (High
risk area)
To improve Nurses competency in taking care of
vulnerable patient
To improve Nurses education about fall prevention
Improve nurses awareness about Fall prevention
methods followed (Grab bars , cot rails, Non skid
slippers etc)
 Duration
4 months (Sep-October-November-December )
Methodology

Auditing of Nursing assessment forms “Fall risk assessment”

Staff interview by “Patient safety nurse”

Sampling size

Full sampling of admitted vulnerable patient

Input
 Daily checking of Nursing assessment forms in all units
 Daily Education of staff nurses in “fall prevention” and “Fall prevention
measures”
 Installation of Side rails in Beds in all areas
 Initiation of installation of grab bars in all patient care area toilets
 Planning to provide “non skid slippers” to patients
 Planning to install of anti skid tiles
 Education of HK staff to keep the patient areas dry /Or to use “wet floor”
board when cleaning
 Advising mothers to stay with children to prevent pediatric patient related
falls
 Planning to introduce a comprehensive “fall risk assessment tool” for nurse
(given for printing)
 Introduced wheel chairs and trolleys with safety belt and lock.
Results
Number of patient falls

Sep Oct Nov Dec

3 0 0 0
Graph
  Fall risk staff nurses not Lack of side Lack of Grab Any history of Number of wheel
assessment not aware of fall rail in Each bars in toilet patient fall in the chairs and
documented in prevention bed unit? Number of stretchers without
Nursing protocols incidences safety straps and
assessment form belt

sep 20(80) 2 9 10 3 3

oct 18(83 0 6 10 0 0

Nov 13(87) 0 0 10 0 0

Dec 7(84) 0 0 10 0 0

Neuro Ward
Findings
It was observed that fall reduction in problem areas
like neuro ICU was reduced to almost 0 % from 100
%(3-0)
Number of beds without bed rails decreased to “zero”
Nursing documentation on fall risk assessment
improved
Recommendations
All areas to be appropriately equipped with patient
safety devices like bed side rails, anti skid tiles, grab
bars etc
Nurses awareness to be Improved
Patient and family education about fall risk needs to be
improved
New “Fall risk assessment forms “ needs to be
implemented
All wheel chairs and stretchers all over the hospital
needs to be equipped with safety straps and belts
QIP –
Prevention and reduction
of bed sore incidence
Programme Members

Staff Nurse –Nursing Quality Dept. Infection

control nurse
Quality executive

Guide:– Medical Director

Facilitators: Nursing Director

AIM

 To reduce incidence of bedsore.

 To improve knowledge of the staff regarding the risk
of bedsore.
 To improve education of the staff regarding preventive
aspect of bedsore.( diet, alpha beds, back care )
Duration
Sep-Dec
Methodology

Daily visit of all patient care areas and patient examination

after intimation from department on “suspected
development of bed sores”

Usage of pressure ulcer grading scale

Sampling size

Full sampling of all patients with suspected bed sores

 Inputs
•Usage of Pressure ulcer surveillance form
•Improved nursing education about pressure ulcers and proper back care
•Substitution of “Spirit” solution which was used for back care with “vasomosa”
solution
•Increased Usage of Alpha beds and Water beds
•Regular Nutritional assessment by dietician
Methodology

Daily survey and examination of “patients with suspected

bed sore development “ by infection control nurse
Daily visiting of all critical care areas- infection control
nurse

Sampling size

Full sampling of all patients with suspected bed sores

Surveillance sheet for pressure ulcers
 Number of bed sore incidence

Sep 19

Oct 16

Nov 14

Dec 12
Graph
Findings
It was observed that bed sores were reduced by almost
37 % (19-12)
It was observed that nurse education was improved on
back care and general awareness on incidence of bed
sores
 Recommendations
•Nurses awareness to be improved about proper back care and care of bed
sores
•Improved and regular monitoring of “critically ill patients” by dietician for
nutritional management
•Water beds to be made available in all critical areas as well as in areas where
patients are prone to acquire bed sores
QIP –
Prevention and reduction
of Thrombophlebitis
Programme Members

Staff Nurse –Nursing Quality Dept. Infection

control nurse
Quality executive

Guide:– Medical Director

Facilitators: Nursing Director

AIM

 To reduce incidence of thrombophlebitis by 50

percentage
 To improve knowledge of the staff regarding incidence
of thrombophlebitis
 To improve education of the staff regarding preventive
aspect
 To reduce incidence of catheter associated blood
stream infection.
Duration
Sep to Dec
 Methodology

 Daily visit of all patient care areas

 Daily Visit and assessment of patients who complain of
onset symptoms
 Daily Visit and assessment of patients who are under
“highly concentrated “ medications (peripheral line)
eg (inj. Vancomycin, Colistin etc)
 Assessment of dressing of peripheral line for signs of contamination with
blood or body fluids

Sampling size

 Full sampling of all patients with lines

 Inputs
• Surveillance for peripheral venous thrombophlebitis
• Labeling of date of insertion over peripheral line and changing every 72 hours
• Reporting from departments by staff nurse to infection control in case of any
• symptoms of infections
• Planning of introducing “transparent “ dressing for easy assessment of infection
• Continuous Nursing education on “ assessment of signs and symptoms of
thrombophlebitis “
• Frequent classes on importance of Hand washing practices for nurses
Months Thrombophlebitis incidence

Sep 10

Oct 6

Nov 7

Dec 6
Graph
Findings
It was observed that Incidence of Thrombophlebitis
was reduced by almost 40 % (10-6)
It was observed that reporting of thrombophlebitis has
improved in patient care areas
Nurses are more aware of signs and symptoms of onset
of thrombophlebitis
Recording of date of insertion over peripheral line has
been improved
 Recommendations
•Antibiotic coated peripheral lines to be put in practice
• Limiting the Duration of intra venous infusions
•Improved Safe handling of the line
•Hand washing practices and usage of PPE’s to be improved
•Planning to introduce policy for administering all high concentrated medicines
through central line