2017 QI Fellows and their QI Projects:

Dr Cara Cochrane
Dr Keith Gomes-Pinto
Dr Rebecca Dyar
Dr Richard Powell

Problem:

‘Medication safety in neonates’

Reported medication errors in our neonatal unit have recently increased. A third of the medication errors are omitted or late doses and there has been a reported medication error at home, and possibly unreported errors. 

Plan:

I am helping lead a project on increasing parent and carer administration of medications during their babies’ stay in the low dependency area of our neonatal unit. If parents and carers were trained to administer medications earlier it may improve their knowledge and confidence. It may reduce medication errors after discharge, as well as relieve the role from the nursing staff during hospital stay and reduce omitted and late doses. We plan to introduce a new Standard Operating Procedure for parent and carer administration of medications, which includes a training checklist for nurses to teach parents and a parent information leaflet on their baby’s medications. Through PDSA cycles we will amend the training and information leaflets provided based on feedback received.

Alongside this I am leading project work to improve prescribing and administration of medications by staff, focussing on human factors. 

Primary Outcome Aim:

We aim to increase parent and carer administration of medication to 50% of babies in our low dependency room over 6 months.  Additionally we aim to improve parent and carer confidence and reduce time spent by nursing staff in giving medications.

We aim to reduce overall medication errors, but promote incident reporting when errors occur.

Problem:

Increasing demand (number of COPD patients)

Reducing capacity (loss of staff)

DNA/Cancellations - 1/3 to ¼ of appointments

Plan:

Increase capacity (reduce appointment time, increase # of COPD review slots)

Reduce DNAs (text-messaging/phone-call reminders)

Reduce Cancellations (patient engagement)

Primary Outcome aims:
Increase number of annual COPD reviews by 10% in our practice over 6 months

Problem:
Details to follow.

Plan:

Primary Outcome aims:

Problem:

Infections related to vascular access are a leading cause of morbidity and mortality for patients receiving haemodialysis treatment.

There was an increase in the number of haemodialysis catheter-related bloodstream infections in our dialysis unit, and the aim of my project is to identify potential reasons for this, and strategies to improve patient safety.

Plan:

I have used a variety of approaches to try to reduce the infection risk for our patients:

1.  Development of a patient safety checklist for haemodialysis catheter insertions, which includes a protocol for MSSA screening and eradication.

2. Collaboration with nursing staff to produce a patient information booklet to advise patients on catheter care.

3. Redesigning the arteriovenous fistula referral pathway, in order to reduce the number of patients requiring a haemodialysis catheter.

Primary Outcome aims:
Reduce incidence of haemodialysis catheter-related MSSA bacteraemias by 50% within 1 year (to less than 2.5 per 100 haemodialysis patients per year)