Preventing Delays to Time Critical Medications

Dartford and Gravesham NHS Trust

Project summary

In July 2021 an incident was reported (LFPSE) whereby the delay in the administration of a time critical medicine resulted in the deterioration of patient’s medical condition & premature death. The initial drug request was processed by Pharmacy, but subsequently misplaced on the ward. A second supply request was generated but could not be fulfilled due to unavailability of stock.

To ensure inpatients receive time critical medications with minimal delay or disruption to their drug therapy we must ensure that we have tight stock controls within the pharmacy department. Tightening these controls should minimise the risk of running stocks to zero, resulting in a reduction of the number of ‘to-follows’ created.

A ‘to-follow’ is created when a drug supply request cannot be fulfilled due to exhausted stocks.

To establish if tighter sock controls of Time Critical Medications (TCMs) were required in DVH Pharmacy, TCM ‘to-follows’ between May 2023 and August 2023 were identified through Prescription Tracking System reports, and then subjected to a series of questions in Pharmacy TCM audit on Gather, in-line with standards set in TCM SOP.

Data revealed that 67 to-follows were processed for TCMs during this period, resulting in 18 missed doses.

Our aim from that point was to reduce the number of to-follows created for time critical medicines for inpatient drug requests by 25% (from weekly average of 3.67 to 2.75) by June 2025.

Our first step was to create a test of change using our Continuous Quality Improvement methodology; we established an in-house TCM weekly stock check. We created a stock list of TCMs identified from audit results, excluding those that are readily available on the ward stock lists and those of high usage. These medicines were to be checked on a weekly basis by the Stores and Distribution Team (setting stock levels in accordance to stock usage on CMM, and proposed figure/level will be that of an average usage over a two-week period to mitigate the risk of running our stocks to zero) and then ordered by Procurement Team.

The results of this test of change were a 67% reduction in the number of TCM to-follows processed, 83% reduction in the number of missed doses, and no reported incidences of patient harm linked to stock unavailability.

One further change implemented to support continuous improvement to project involved a TCM presentation incorporated in ‘safe dispensing’ workshop for dispensers/ATOs and now included in local pharmacy induction.