Exploring key risks in the medical admissions process

AbstractThis study investigated the hospital admission process in relation to two areas associated with known patient related risks, venous thromboembolism (VTE) risk assessment and medicines reconciliation in an English teaching hospital Acute Medical Unit (AMU). National guidance was available at the time of the study for both of these aspects of care. Government targets with associated financial penalties were set for VTE risk assessment in 2010, there were no similar targets for medicines reconciliation.NHS ethics approval was granted. A novel mixed methodology was used involving direct observations of the patient admissions process, interviews with staff and an audit of case notes. Data were collected over four one-week periods between 2009 and 2011, 36 staff were observed admitting 71 patients, 44 staff were interviewed (25 VTE, 19 medicines reconciliation) and 930 sets of case notes were audited.The observations showed that at the start of the study guidance was rarely followed for both VTE risk assessment and medicines reconciliation. Staff were unaware of its existence and ignorant of the both the associated risks and the level of guideline compliance within the organisation. There were low levels of compliance with local and national VTE guidance until national financial sanctions were introduced when significant increases in the rates of both VTE risk assessment and appropriate prescribing of prophylaxis were seen, however inappropriate prescribing also rose. Observations showed poor medication history taking and prescribing practices, during the study the proportion of items with a prescribing error increased, however the interviews showed that staff did know how to establish an accurate medication history and were aware of the potential problems.A national financial sanction was associated with the effective implementation of VTE guidance however it remains to be seen whether standards can be maintained in a complex high pressure environment. Organisations must also be aware of the potential for unexpected adverse outcomes. Prescribing errors may be reduced if a mechanism can be found to ensure that theoretical knowledge is routinely translated into practice, however greater pharmacy involvement before the admission prescription is written should also be considered