Emergency Department Prescribing Audit (2017/18)
Problems & Aims
A previous prescribing audit (2013) indicated that our Emergency Department did not provide safe and effective documentation in relation to UHL prescribing guidelines and specific audit standards. The main recommendation from the previous audit suggested a change in our prescription charts.
That was implemented in 2014, so this audit aims to determine whether the introduction of a new prescription chart has improved our documentation when prescribing?
Methodology
We carried out a retrospective data collection of 100 patient’s notes – both adult and paediatric patients – who had presented to the Emergency Department between 1st December 2017 and 1st March 2018 and received prescribed treatments.
No patients were excluded from the audit.
Medications were prescribed by medical staff, non-medical prescribers and nursing staff using PGDs.
Audit Standards 2017-18
Name of prescriber is identifiable
Name of administrator is identifiable
Time of prescription documented
Time of administration documented
Amount of opioid administered documented
Results & Comparisons
Recommendations
Nurses to use their unique 3-digit code to help identify their signature.
To develop local standards as to what constitutes legibility i.e. mandatory use of identifiable stamps or printing of name +/– registration number.
Discussion
Redesign of the prescription chart has shown a marked improvement in the safe and effective documentation of prescriptions within the ED.
However, a significant number of prescriptions still reflect illegible prescribers and/or administrator’s details.
Current guidelines and standards require prescribers and those who administer medication to record their actions “clearly, accurately and
legibly” – GMC, NMC & NICE
However, there does not appear to be any national standard on what constitutes as ‘legible’.
References
Nursing and midwifery council (2015) the code for nurses and midwives. www.nmc.org.uk
General Medical Council (2013) good practice in prescribing and managing medicines and devices. www.gmc-uk.org/guidance
National Institute for Health and Care Excellence (2017) supporting junior doctors in safe prescribing. NICE (London)
