“Would you like your blood thinning tablets?”. The nurse asked the question very sweetly, but it was a troubling question.
Because my young relative, waiting for their cardiac ablation, had already had their dose of Dabigatran. “Oh, sorry – my colleague didn’t tell me they’d already given it to you”. If I hadn’t been there to intervene, my relative could have suffered catastrophic bleeding during the procedure.
Giving a young person a haemorrhagic stroke is an expensive mistake. It is incidents like this that explain why medication error is such an economic burden. In the UK, in 2014, the cost was estimated at £2.5bn. A more modest estimate of £98m was suggested by researchers in Sheffield in 2018. But their accompanying statistics are even more frightening: 181,626 bed- days lost, and 1,708 deaths. And this is only one country.
This is why, in 2017, the WHO targeted medication safety in its third global patient safety challenge.
The WHO estimate is that medication harm costs £42bn, or 1% of all healthcare spending. Risk factors singled-out by the WHO are polypharmacy, high-risk medications, and transitions of care.
Although the WHO emphasises transfer across organisational boundaries in their definition of transitions of care – the same issues affect other transitions: handover between individuals within a team (the Dabigatran incident is an example ) and referrals between teams within the same organisation.
In each of these levels, three things are essential.
First, staff must have care plans which are highly visible, and shared across multidisciplinary teams. Doctors, nurses and AHPs need to see the same record – updated in real time. This means we need to eliminate the informal systems, the ‘pieces of paper in the back pocket’
Second, plans need to be detailed enough to provide clarity at the task level. A plan which simply says “Continue; review mane” may be convenient for the consultant, but it’s no help if we want to know what has been done, by whom and what tasks remain outstanding.
Finally, care records need to be forward-looking, not just retrospective. The Harvard Business Review recently discussed the future of health records and – for the most part – this is the major change that is needed for patient safety.
The CAREFUL platform offers users the opportunity to work at all these levels, which provides users with a forward looking, task-oriented way of managing handover using mobile and desktop using technology which is easy to use.