Safer Clinical Systems: Royal United Hospital Bath NHS Trust

  • Run by a team at Royal United Hospital Bath NHS Trust.
  • Ran from October 2011 for 2 years.
  • Focused on patients with Parkinson’s disease
  • Aimed to improve reliability in medication prescribing and administering through hospital admission and back to the community again.
  • Designed to develop a greater understanding of prescribing risk factors, and then to consider how hospital systems could be restructured to improve safety. 

A team at Royal United Hospital Bath NHS Trust worked on a project focused on patients with Parkinson’s disease. The project aimed to improve reliability in medication prescribing and administering through hospital admission and back to the community again.

Prescribing errors are common in clinical situations. If people with Parkinson's disease don't get their medication on time, their ability to manage their symptoms can be lost – for example, they may suddenly not be able to move or get out of bed. Around 900 people with Parkinson’s disease live local to the Royal United Hospital Bath. Between 12 and 20 are admitted every month. Improving medication safety was identified as an area where the hospital could have a significant impact on care for people with Parkinson’s disease.

This project aimed to explore the factors influencing safe drug administering and address the following issues:

  • patients missing out on doses of medication
  • repeat prescriptions with errors
  • breakfast time as a high-risk interval for missed doses
  • poor documentation.

By first developing a greater understanding of prescribing risk factors, the project set out to consider how the hospital's systems could be restructured to improve safety.

The team aimed to improve reliability of drug administering, concentrating on Parkinson’s disease, and ultimately to change the culture around medication safety more broadly. The project set out to significantly improve systems to ensure that medication delivery – an essential part of inpatient treatment – is performed reliably. 

Further reading

Research report

Safer Clinical Systems: Evaluation findings

Lessons from the second phase of the Safer Clinical Systems programme.

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