Learning from others to prevent future deaths
Consent is a fundamental principle underlying the care and treatment we provide in our hospitals. But what happens if a patient rejects clinical advice?
This was the dilemma faced by colleagues at Whipps Cross when a patient persistently refused essential medication to prevent blood clotting.
It was never entirely clear why, and later after the patient died, the coroner issued a prevention of future deaths order, noting that the missing doses were likely to have contributed to his passing.
There was also no documented evidence that the risk of non-compliance with the medication had been explained to the patient or escalated to the medical team.
So, colleagues on Rowan and Primrose wards set up a quality improvement project to investigate and learn lessons from the incident. They discovered that over a three-month period, over 1,000 doses of critical prescribed medication were missed; one-third because patients refused.
The root cause analysis suggested that even when ward staff explained the potential consequences of missing medication, this was often not documented or escalated.
Many (but not all) of the failings occurred during bank or agency shifts, and exposed doubt on the accuracy of some clinical records.
Staff tested different change ideas, including enhanced training and improved availability of stock, and overhauled the process for managing missed doses.
The result was a measurable reduction in workflow failures from 37% to 16%, improving protection from preventable complication.
Shahida Trayling, the hospital’s director of nursing and governance, told the recent quality summit: “Staff now consistently ensure patients have capacity, that they educate patients so that they can make an informed decision, document when medication has been declined, and inform medical teams when this occurs.
“We also have safer and clearer processes, more accurate clinical records, and better availability of drugs. Most important of all, these changes result in a reduced risk of harm to our patients.”