How many ways are there to die? Identification of ICU death typologies using cluster analysis
Introduction We aimed to audit the prescribing practice on a busy 14-bedd general ICU, and develop standardised practices and tools to improve safety. Prescribing errors occur as commonly as in 10% of UK hospital admissions, costing 8.5 extra bed days per admission, and costing the National Health Service an estimated £1 billion per annum . The majority of these mistakes are avoidable . Methods We audited the daily infusion charts of all patients in three separate spot checks, over 1
... We assessed all aspects of prescriptions that make them legal and valid, in accordance with national guidance . New procedures were introduced, which included a standardised prescription sticker, with common, preprinted, infusion prescriptions on (noradrenaline, propofol, and so forth), and education on using the new prescription stickers. A month later the audit process was repeated. Results We assessed 129 prescriptions in the fi rst round, and 111 after intervention, demonstrating a 70% improvement in safe prescribing. Only 24% of prescriptions initially fulfi lled best practice criteria, improving to 94% afterwards. We also reduced the number of infusions running without prescription, 7 (6%) versus 24 (19%). See Figures 1 and 2 . Conclusion Our audit supports the need for standardised prescribing practices within critical care, especially when dealing with potentially harmful vasoactive/sedative drugs. With a small, cost-eff ective intervention (£20 for 6,200 stickers), we improved prescribing accuracy, and thus patient safety in intensive care. P2 The Limpet controlled drug cabinet alarm and camera M Mariyaselvam, D Pearson, P Moondi, P Young Results Mock thefts were successfully accomplished on six occasions over a 4-week period. On each occasion the Limpet photographed the 'thief' and recorded the date and time of access. Therefore, in the event of a real theft it would be possible to quickly and easily indentify the culprit. Conclusion When CDs are missing it can be extremely stressful for the staff involved. Those who have access to CDs may feel unfairly scrutinised and the potential for false accusation exists. Investigating the theft of CDs is costly and usually involves pharmacists, managers and the police. Until the issue is resolved, potential suspects are usually suspended from work, leading to disruptions in patient care. The utility of the Limpet in modifying staff behaviour by reducing the number of occasions and the duration of time that open drug cupboards are left unattended, has previously been demonstrated . By providing the facility to determine exactly who accessed each CD cupboard at which time, this initial study has shown the benefi ts of the Limpet as a tool for detecting theft. Therefore the installation of the Limpet mitigates the diffi culties of investigating CD theft and is likely to prove an eff ective deterrent. Reference 1. The Limpet drug cabinet alarm: technology for safer drug stewardship [abstract and poster presentation].