Summary of the example
We aimed to make self-administration more easily available to patients who wanted it.
We conducted a failure, modes and effects analysis, collected baseline data on four wards and carried out observations. This initial assessment suggested that the main areas we should focus on were raising patient awareness of self-administration, changing the patient assessment process and creating an improved storage solution.
We developed new patient information leaflets and posters and a doctor’s assessment form using Plan–Do–Study–Act cycles. We developed initial designs for a storage solution but were not able to take these forwards during the duration of the project. We piloted the new materials on three wards.
Following collection of baseline data, we continued to collect weekly data. We found that the proportion of patients who wished to self-administer who reported that they were able to do so, significantly increased from 41% (of 155 patients) to 66% (of 118 patients) during the study, despite a period when the hospital was over capacity.
We learned that raising and maintaining healthcare professionals’ awareness of self-administration can greatly increase the proportion of patients who wish to self-administer who actually do so. Healthcare professionals prefer multi-disciplinary input into the assessment process.
Why we think it’s important
It is well known that medication errors occur when patients cross healthcare settings. The importance of involving patients with their medication to enhance safety is increasing. Such involvement can increase satisfaction, improve health outcomes and reduce the likelihood of avoidable harm. There is evidence for benefits of self-administration of prescribed medication in the hospital setting. Systematic reviews suggest some significant improvements in patient satisfaction, knowledge and compliance, although findings have been inconclusive. More recently, it was found that significantly fewer doses were omitted in patients self-administering in hospital than when medicines were administered by nurses. The same study also found that patients not self-administering were more likely to have omissions of critical medicines with greater potential for harm.
Patient and public input at our London teaching hospital has suggested increasing self-administration as a means of building relationships between inpatients and healthcare professionals and improving transitions of care by maintaining patients’ independence when moving from the home to hospital setting and providing a seamless transfer from hospital to home.
Learn more about the example
Aims and objectives of the work
Our primary improvement aim was to increase the proportion of patients who wished to self-administer who were able to do so. A secondary aim was to improve documenting and reporting of self-administration. We wanted to overcome specific barriers to self-administration of medication which previous research had suggested were in place at our hospital organisation. These included patients not being aware of the option of self-administration and the assessment process being perceived by staff and patients to be very arduous.
First, we conducted a failure modes and effects analysis to identify risks associated with self-administration. We had input from three pharmacists, one medical consultant, one ward manager, one specialist diabetes nurse and four members of the public. Main risks were:
- Patients without consistent capacity allowed to self-administer, leading to missed doses or poor adherence
- Patients suitable for self-administration not being allowed to do so, leading to delayed doses for patients who need medications at specific times and increased risk of poor administration of medication after discharge.
Second, we collected baseline data on three wards; an acute medical ward, an endocrinology and rheumatology ward and a private ward. We collected data to inform the following measures:
- Proportion of all patients recorded as self-administering medication.
- Proportion of all patients reporting being aware of the self-administration option.
- Proportion of patients who wished to self-administer their medication who reported that they had done so.
- Proportion of patients self-administering medication who had the correct assessment paperwork completed.
- Proportion of patients reporting that they had self-administered who were recorded as doing so.
Third, we carried out observations of doctors, nurses and pharmacists.
Fourth, we used Plan-Do-Study-Act cycles to:
- Increase patient awareness of self-administration through improvement of leaflets and development of posters;
- Change the assessment process to make it simpler and multidisciplinary between doctors, nurses and pharmacists, rather than the sole responsibility of nurses.
We had input from hospital patients, designers, members of the public, medical consultants, nurses, pharmacists, the hospital’s communication team.
We continued to measure metrics as for baseline data throughout the project and identified significant changes using p charts and statistical process control methodology.
The p charts showed that from the point when we began increasing our presence on the ward and having discussions with healthcare professionals about self-administration, there was a significant and substantial increase in the proportion of patients who wished to self-administer who actually did so. The proportion increased from 41% of 115 patients to 66% of 118 patients during the study, from baseline, despite the hospital being over capacity at one period during the study. There was also a small but significant increase in patients being recorded as self-administering.
We found that following a quality improvement day, which was attended by three nurses who worked on one of the study wards, the number of patients with the correct paperwork dramatically increased for a short space of time but this was not sustained.
There were no other significant changes.
Some patients made informal comment, after the leaflets and posters had been implemented, reporting that they were self-administering their medicines as a result of seeing the posters. Healthcare professionals also told us that they were aware of the project and had seen the leaflets and posters.
Our project suggests that raising healthcare professionals’ awareness of self-administration can greatly increase the proportion of patients who wish to self-administer who are actually able to do so.
However, our findings also suggest that in order to sustain improvement, awareness needs to be a continuous rather than a one-off process. The improvements seen following the quality improvement day, a one-off event, were not sustained. In contrast, those seen following more continuous awareness-raising on the study wards were sustained for the duration of the project.
No unintended consequences were seen.
Our Self-Administration of Medicines (SAM) Policy, which has had local governance approval, has leaflets, posters and new assessment process included as appendices (attached below).
National guidance, data and publications
This work has been published in the International Journal for Quality in Healthcare:
S Garfield, H Bell C Nathan S Randall et al. A quality improvement project to increase self-administration of medicines in an acute hospital. International Journal for Quality in Health Care, Volume 30, Issue 5, June 2018, Pages 396–407 (see link below).
In addition we used our findings to input into the Royal Pharmaceutical Society’s consultation for the revised version of their professional guidance on the safe and secure handling of medicines.