Abstract
Background: Accurate documentation of medication suspension is crucial for patient safety, especially during transitions such as out-of-hours discharges. In early 2023, an audit in our hospital’s elderly care ward revealed a significant number of medications were suspended without proper documentation, raising concerns about continuity of care, medication errors, and patient outcomes. This Quality Improvement Project (QIP) aimed to improve the consistency, clarity, and quality of documentation in the ward to enhance patient safety and reduce risks associated with incomplete information.
Methods: The project consisted of three cycles. In the first cycle, retrospective data from 29 patients showed 33 medications were suspended, with only 18% having a documented rationale. Following this, interventions were implemented, including raising staff awareness through handovers and posters displayed throughout the ward. These interventions aimed to highlight the importance of proper documentation in clinical practice. In the second cycle, data from 23 patients revealed 42 suspensions, but 24% still lacked documentation. Further steps included assigning responsibility to each clinical team member for ensuring proper documentation during their shifts. In the third cycle, data from 30 patients showed 82% of 31 suspended medications were documented appropriately. To address remaining gaps, a proposal was made to introduce a mandatory rationale field in the Electronic Prescribing and Medicines Administration (EPMA) system to ensure consistent and comprehensive documentation.
Results: The project led to progressive improvements in documentation, increasing from 18% to 82%. The proposed enhancement to the EPMA system aims to achieve near-total compliance and further streamline documentation practices, ultimately improving patient safety.
Conclusion: This QIP significantly improved documentation of medication suspensions, enhancing patient safety and care continuity. Ongoing education, monitoring, and system improvements will be essential to sustaining these advancements and ensuring thorough documentation in clinical practice. Regular audits, feedback mechanisms, and increased engagement with clinical staff can further reinforce the importance of maintaining high standards of documentation to prevent medication errors and optimize patient care.