It’s relatively straightforward to change policy and procedures, but to change culture is a real challenge. However, this is what Aberdeenshire Council has achieved in its staff’s approach to medicine administration at its Very Sheltered Accommodation complexes around the county
When Jackie Bradford took up the position of Coordinator of Doocot View Very Sheltered Accommodation in 2016, she quickly realised that there was an issue with medicine administration. Her 30-flat complex, in Banff, was reporting an unacceptably large volume of medication errors. And it was not just Doocot View, as a number of the other Very Sheltered Housing (VSH) complexes in Aberdeenshire were also reporting a large number of errors.
Medicines had routinely been missed, incorrect doses given, or administered at the wrong time, as well as not being signed for.
This situation had already been raised by the local Care Inspector Frances Clark, with Michael Smith, who managed the Very Sheltered Housing and Day Care Services across Aberdeenshire.
Michael, together with Rhoda Hulme from Aberdeenshire Council, brought a team together to review the medication administration policy and also sought advice from David Marshall, the Care Inspectorate’s Health Improvement Adviser – Pharmacy.
David was impressed with the council’s commitment to move to a collaborative working model as a way to deal with the medication errors and use them as an opportunity for staff learning and to improve competency.
David explained: “Most errors are conducted by people who know what they are meant to do and aim in general to do a good job. It’s just that there are other reasons why they do not do what they should. We have known for ages that a person-based blame culture does not work long term, and that a systems-based learning approach is better, but it does involves a significant change in culture, and that’s not easy to achieve.”
David explained the new approach to the VSH coordinators and they went back to their services to implement a number of new practices to improve medication administration.
Jackie said this new approach has helped turn her service around. She explained: “In the previous year, before I took up the post in 2016, we had 376 errors in a year, which is at least one a day. But last year this went down to 136 on 99,796 individual medical administrations, so it shows that we have made significant improvements.”
These have been achieved by a number of audits and staff support initiatives as well as a wallchart, updated weekly, that helps staff to focus on the importance of medicine administration for the people they care for.
The first step was to make the Medication Administration Record (MAR) sheet easier to use – it was redesigned in an A3 portrait format to make it clearer to follow and record information. This was refined further by colour coding the times when an individual’s medicine needed to be administered, such as green for morning, yellow for lunchtime, and so on.
As well as introducing a more stringent process for staff to check MAR sheet details with the medicines supplied during the medicine administration process, the assistant co-ordinator will also conduct a single random audit once a day Doocot View, like the other services, has introduced competency training where a staff member is observed during their medication administration practice for three different residents, and this is repeated every three months. This is also backed up with a peer support initiative, which involves three administrations, two of which are observed by a colleague and one by the assistant co-ordinator.
If everything is satisfactory, the staff member is signed off as competent. If not, Jackie will discuss areas where the service can support them to become competent.
Jackie said: “It might seem excessive, but the focus is on observing practice and offering support. We acknowledge that everyone can make a mistake, but the focus should be about learning from these errors.
“If there is an error, then the conversation is about what support we need to put in place to help the person become competent in medication administration so they do not make these errors in future.
“I think the peer support is very powerful, as it gives people the opportunity to look at how their colleagues administer medicines and pick up good practice that they can incorporate into their work. Therefore, people are not told what to do, but they can observe and reflect on their own practice and change it for the better.”
Where a mistake has been identified, there is a process for the person to reflect on how it occurred. Looking at the root causes of incidents can help to focus on what changes can be made to help them avoid the same mistake.
Jackie added: “As part of this reflection, we make them aware of the potential consequences of a resident not taking that medication. It’s not to scare them, but to help them realise the importance of the medication for the tenants they care for. We then go through the process and see if there is anything we can do to support them to improve their competency.”
Each staff member carries a small postcard aide memoire with them, which gives a checklist for medicine administration process that they can refer to.
The service’s performance in medicine administration is highlighted in a wallchart, which is updated weekly in the staff room. Green means no errors, but a red mark is added when there is a notification to highlight the flat and medication error.
Jackie added: “When they see the wallchart is all green, they are quite thrilled by it but, equally, it’s disappointing to see a red dot on it. However, it makes us all resolved to make sure it does not happen in the next week.”
Next to the wallchart are pie charts that were originally developed by a social work student on secondment to Doocot View, who analysed medicine administrations and errors at the service over a 12-month period.
He also broke down the different categories of errors and this trend analysis is updated monthly, highlighting to Jackie and her team where to focus extra training if required.
Jackie added: “There are lots of demands on our staff during their medicine administration rounds, so that is why all our work is focused on support rather than blame.
“We’ve now developed a culture where our staff come to us to highlight an error so we can all work together to rectify that mistake for the benefit of the wellbeing of our tenants.”
Frances was impressed with the change at Doocot View during her recent inspection. She said: “The fundamental change in the service’s improvement is that the blame culture is no longer there. This has had a positive impact and enabled staff members to have more confidence in medicine administration and to also reflect on their practice and share best practice.
“As a result of the systems in place, increased knowledge and non-punitive action, medication errors within Doocot View have greatly reduced.”
David added: “I hope the work done here to manage incidents, and the positive outcomes seen, will act as an inspiration – if needed – for other services to adopt a systems-based learning culture.”