ECNI-2.4 – Stop before you start!

When we see a problem that we want to solve, or an opportunity to improve, we usually want to jump straight in and make it happen. But don’t’!

The danger of leaping to action is that we might not be tackling the right problem or implementing the right solution. The first idea is not always the right, best or only idea and there may be more the problem than we first realise.

So before you start – stop! Stop and observe what really happens now… Once we have seen what really happens now, we can generate appropriate ideas for change.

In this section, you will see how Elizabeth put this into action in her improvement project to decrease drug errors in the home / on the ward where she works. But first of all, watch the film below to see how observant you are…

If we are focusing on a task, we may miss what else is going on around us. This is why it is important to deliberately stop before you start, observe and notice before leaping to action.

Observing drug administration

Elizabeth was worried that she could not be 100% sure about her own – or others’ – possible drug errors on the ward. She knows she wants to do something about this, but before she decides exactly what, she decides to observe what is happening now, so that she understands what might really be going on and what she might be able to do to improve things.

Have a look at the examples below to find out what she sees. What do you notice?

Elizabeth’s observations

It was important to address the needs of Scott and the patient and the following steps were taken:

  • Reported the incident and a duty of candour conversation was undertaken at the patient’s bedside
  • Elizabeth along with the matron and senior doctor on call visited the patient and supported Scott when apologising for the mistake
  • The patient was given a full examination and bloods were taken
  • The patient was told of the option to talk to the patient liaison team
  • Elizabeth then worked with Scott on the late shift to ensure he regained his confidence around administering medications and consolidated his good practice
  • Elizabeth also informed Scott that in line with local policy, there was a need to complete a written reflection, highlighting his learning and discussed with his manager at his next 121.

Luckily, no further harm came to the patient as a result of the drug error, but Elizabeth wanted to invesigate the issue more broadly to correct bad practice before a patient is harmed.

Now that she had spent some time observing what happens day to day, she could see that there were times when everyone might be making mistakes. She wanted to make things better and that meant working out exactly what she wanted to achieve and where to start.

What is the problem we want to solve?

What Elizabeth has noticed:

Elizabeth decided that she wanted to consolidate her learning around medicines management and administration and become a medicines management champion to support other newly registered nurses to learn from her experience and reduce medication errors on the ward.

We will see how she refines her aim and starts to make changes in the next section. Before you move on, let’s take stock and think about how you can apply this in your own work.

Review the document below to revisit the 6 Rights if Medicines Management.

6 Rights of Medicines Management

To avoid medication errors, good practice is to observe the 6 rights of medicines management.

  • Right Patient
  • Right Time
  • Right Medication
  • Right Dose
  • Right Route
  • Right Documentation

NICE: Discussing and planning medicines support

Nursing Times: How to avoid drug errors: the five “rights” of medicines administration

RPS: Professional Guidance on the Administration of Medicines in Healthcare Settings

What we are trying to achieve

Start with thinking about the problem you want to solve. What are the pebbles in your shoe? Think about things that are ongoing irritations (don’t start too big!)

What will you do?

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