Evidence-based kwaliteit verbeteren

Summary

Evidence Based Quality Improvement, a recipe for improving medication safety and handover of care
Marian Smeulers

AIM: This thesis explored the required ingredients for evidencebased quality improvement (EBQI) of two processes with high potential for errors: the medication (preparation and administration) process and handover of care.
METHOD: The study was performed at a teaching hospital in The Netherlands. For both topics, studies with initial analysis techniques were followed by intervention studies to establish measurable effectiveness. A combination of quantitative and qualitative methods as well as literature review were used. In medication safety, a qualitative interview study and observational study were used to assess the extent of the problem. In a before-after design, effectiveness of medication tabards was established. For the handover topic, a literature review combined with a formal consensus procedure resulted in a local blueprint for nursing shift handover. The effectiveness of the blueprint was evaluated using an interrupted time series design.
MAIN FINDINGS:
Medication safety
Besides safe preparation and administration, nurses have a role in the continuous assessment of a patient’s condition in relation to the medications prescribed. However, their ability to adequately perform this role depends on sufficient knowledge to assess the risks of medication administration and on the circumstances in which they work. Suboptimal circumstances during medication preparation and administration are caused by frequent interruptions (6.9 times per nurse each hour). Drug round tabards were effective in improving medication administration safety with a decrease of 75% in interruptions, 66% in medication administration errors and a significant linearity between interruptions and MAEs (R2 of 10.4%). However, from the nurses’ experiences it became clear that they have mixed emotions about wearing the tabard. Finally, a literature review identified several indicators for safe inhospital medication preparation and administration. These quality indicators partially cover the 7 rights of safe medication administration.

Handover of care
Best available evidence on the most effective nursing handover style provided the following guiding principles for redesigning the nursing handover process: face-to-face communication, structured documentation, patient involvement and use of information technology to support the process. The formal consensus process combined these principles with local expert opinion which resulted in a local nursing shift handover blueprint with a bedside safety check. The pilot implementation of the blueprint showed a positive trend with a further increase of high scores and decrease in low scores. The introduction of the bedside safety check was highly appreciated and mainly intercepted discrepancies with drains and intravenous medications. Furthermore, it gave the nurses a more complete clinical picture and a well prepared feeling at the start of their shift. The pre and post measurement periods were too short to assess conclusive results on the effectiveness of the nursing handover blueprint, but a time series analysis can be used to analyse quality of handover as an outcome measure.

DISCUSSION AND CONCLUSION: Drug round tabards are an effective intervention for decreasing interruptions and medication administration errors. A structured handover with a safety check at the bedside appears promising for improving the quality of handover. However, both interventions require further development and more rigorous testing to obtain high level evidence of their effectiveness. A practice based iterative design and small scale evaluation of quality improvement interventions that build up towards rigorous research designs and long term measurement of effectiveness as well as implementation is recommended for complex interventions. It enables testing of outcome measures, fine tuning of the intervention and helps to determine barriers and facilitators for implementation. Finally, it is important that healthcare professionals and leaders have sufficient knowledge and skills for quality improvement. They are a critical success factor to systematically work together on continuous quality improvement.