Reflective
Outline and discuss a clinical audit that you have undertook into one aspect of care delivery and reflect upon the experience using Driscoll’s model of structured reflection. Word Count (2197)

During the course of this piece of work, it is my intention to outline and discuss a clinical audit that I undertook into one aspect of care delivery and reflect upon the experience using Driscoll’s model of structured reflection (Driscoll, 2000). The audit, which focused upon the completion of prescription cards, was undertaken during my recent clinical practice placement at Holcroft, a twenty four bed mental health residential unit, situated in the North West of England. In addition to providing a summary of the exercise itself, I would also hope to explore the relationship between the clinical audit process and the wider framework for quality improvement in healthcare. The development of regulation and clinical governance systems in the United Kingdom will also be addressed as will the administration of medication as a significant element of nursing practice. Where necessary, use will be made of academic, research and other evidence based material to underscore or augment specific issues or indeed illustrate examples of good clinical practice. The Nursing and Midwifery Council (NMC) standards for conduct, performance and ethics (NMC, 2004) have been diligently applied in the construction of this assignment. Pseudonyms will therefore be used to ensure staff and patient confidentiality, whilst other identifying information will be completely anonymised. Clinical governance, a term first introduced in a government White Paper The New NHS: modern, dependable (Department of Health, 1998) is a notion that has attracted a range of definitions (Nicholls, Cullen, O’Neill and Halligan 2000, Starey, 2001) but can broadly be defined as a comprehensive framework to improve the quality and consistency of healthcare within the National Health Service (NHS) and other healthcare organisations. In its quest for improvements in clinical quality and the reduction of unacceptable variations in patient care, the present labour government have, during their period of office, launched a number of initiatives and policies that it hoped would bring about a new system of healthcare within the NHS, one based upon partnership and cooperation rather than competition and driven by improved performance outcomes (James, Worrall and Kendrall, 2005). The National Institute for Clinical Excellence (NICE) was originally set up in 1999 to appraise new and existing treatments, produce clinical guidelines and set national standards for healthcare. In April 2005, it joined with the Health Development Agency to become the new National Institute for Health and Clinical Excellence, although its role and functions remained largely unchanged. National Service Frameworks (NSF) 2

developed from 1999 and sought to explicitly set out common standards and identify key interventions for a defined care group, service or provision in certain key areas such as mental health, coronary care and diabetes. The Healthcare Commission, a statutory body that took over the workings of its predecessor, the Commission for Health Improvement in 2004, is responsible for monitoring standards and working to promote improvements in various areas of healthcare. Together, the National Institute for Health and Clinical Excellence, National Service Frameworks and the Healthcare Commission played a major part in the identification of best healthcare practices and treatments, the determination and setting of universal standards and the monitoring and promotion of improvements in healthcare at a national level. The Government’s vision for the continuing development and modernisation of UK health services found further expression in The NHS Plan (Department of Health, 2000). In what was promised to be the most significant and far reaching restructuring of healthcare in England since the inception the NHS itself, the document mapped out how increased funding and reform would serve to redress geographical inequalities, improve service standards and extend patient choice. It also proposed new systems to enhance patient care, an emphasis upon health and wellbeing rather than illness and the increased devolution of decision making to local organisations. The need for more partnerships and joint working arrangements between Primary Care Trust’s, Local Authorities, independent and voluntary sector organisations, was also emphasised. A new performance framework was also implemented in April of 2005, Standards for Better Health (Department of Health, 2004) which sets out the level of quality all organisations providing NHS care are expected to meet (core standards) or aspire to (development standards) within UK healthcare. The standards to which the document refers are organised within seven domains ranging from safety and governance, to patient focus and public health and are designed to cover the full range and spectrum of healthcare as enshrined in the Health and Social Care (Community Health and Standards) Act 2003. National Service Frameworks and National Institute for Health and Clinical Excellence guidance are integral to this standards based system, whilst The Healthcare Commission has an ongoing and major function to play in the assessment and review of all healthcare organisations.

Whilst there has and continues to be widespread debate, the elements of clinical audit, research, continuing professional development and reflective practice are generally included within the concept of clinical governance and although such notions are not in themselves new, their integration into one overarching framework is a relatively recent development, as indeed is the move towards service user empowerment and increasing partnerships between patients and professionals (Scally and Donaldson, 1998). Clinical audit is regarded by many as a quality improvement process that seeks to enhance patent care and other outcomes, by and through the application of management techniques within a clearly defined quality assurance framework (National Institute for Health and Clinical Excellence, 2002). At its simplest, clinical audit involves the systematic measurement of specific healthcare practices or aspects of them, against given or explicit standards. It is a key component of clinical governance and central to the ongoing effectiveness of any healthcare organisation. (NHS Executive, 1999) Indeed, without the process of clinical audit, it is difficult to conceive how poor practice or service delivery in various areas of healthcare might be identified, let alone refined, modified or changed to bring about more positive or improved outcomes. Furthermore, the setting of clear and transparent standards and the publication of data derived from clinical audit studies has the very real potential to provide reassurance to patients, practitioners and managers that an agreed quality of service is being provided within specific healthcare areas (Wilson, 1998). The clinical audit I undertook during my clinical practice placement focused upon patient prescription cards within Holcroft. The writing of prescription cards is perhaps one of the most common activities of doctors involved in patient care and in the treatment of various mental health conditions this task is perhaps of even greater significance. In the administration of medication, the accuracy of information contained in the prescription card and role of the nurse to interpret, comply with or indeed query particular instructions is a fundamental and integral element of clinical practice and one that is itself subject to strict professional and legislative control (NMC, 2004) Indeed, a report by the Department of Health identified prescribing mistakes as the single most common type of avoidable medication error (Department of Health, 2001). However, despite the significance of prescribing errors and their role in impeding improvements within UK healthcare, there have been relatively few

studies into this area of clinical practice (Dean, Schachter, Vincent and Barber, 2002) and even fewer that involved prescriptions for psychiatric patients (Paton and Gill-Banham, 2003). The majority of these studies found errors in prescription writing and transcription to be central, rather than clinical decision making and called for improvements in the design of prescription cards and clearer guidance in their completion by medical and associated personnel (Haw and Stubbs, 2003). Although the exercise I completed was neither detailed nor protracted, it allowed one particular aspect of the existing medication protocol within Holcroft to be objectively assessed on the basis of a single concurrent audit. Its objective was to evaluate the extent to which patient prescription cards were completed accurately and in accordance with both agency policies and NMC guidelines. To assist in the systematic evaluation of each prescription card, I constructed an audit tool/checklist (Appendix 1) which listed a range of standards pertaining to both patient information (7) and prescription content (11). The audit tool I developed was informed by a range of literature I had reviewed for this purpose, particularly the work (Onalaja, Safrey, Jones and Bentham, 2001) and (Stubbs, Haw and Cahill, 2004). Variables of yes and no were used to assess the accuracy of patient details and to reflect the presence or absence of specific information in this section. Data pertaining to prescription content was collated using a numeric system in order that the number of specific errors identified within each prescription element could be shown precisely, thereby allowing a more accurate analysis of the information derived from the audit process itself (Appendix 2). In carrying out the clinical audit, the criteria elements that I had set out to check (Appendix 1) were applied to the prescription cards of the unit's population of twenty one residents. I carefully and systematically reviewed the information on the actual prescription cards and compared this against the specific criteria elements that had been identified. A colleague also double checked a random selection (twenty five per cent) of the cards in order to promote quality assurance and indeed ensure that the audit process was both rigorous and methodologically sound. As many residents received between two and seven different forms of prescribed medication, the audit evaluated and verified a total of 1371 separate pieces of information. In all, three errors were encountered (Appendix 2). The first related to the illegibility of an entry

linked to the dose of Clozepine. The figure cited could have easily been mistaken for a dose of one, four or seven hundred milligrams of the product. The second error pertained to the incorrect spelling of Diazepam whilst the third omitted to indicate the route of another prescribed substance. Although the second and third errors were both relatively minor, the ambiguity of the Clozepine prescription was clearly more significant, especially if the higher dosage of seven hundred milligrams were to have been administered on a frequent and regular basis. In this regard, I immediately brought my findings to the attention of the Holcroft’s manager and action was taken to clarify the patient’s correct dosage on their prescription card, pending arrangements for it to be rewritten by the responsible medical officer. The clinical audit I conducted at Holcroft into the completion of patient prescription cards and the research associated with it has been decidedly useful. The exercise itself has allowed me to acquire a basic understanding of the various developments that have taken place within the NHS to promote quality in healthcare services during the current government’s term of office and heightened my awareness of the policies and agencies that have assisted in this process. I am now familiar with the role of the National Institute for Health and Clinical Excellence, the purpose of National Service Frameworks, the function of the Healthcare Commission and understand their significance in the modernisation of the NHS (Department of Health, 1997). More recent developments, such as the performance framework set out in Standards for Better Health (Department of Health, 2004) have served to not only to illustrate the intimate relationship that exist between social policy and legislation, but also the way in which public opinion and the political process itself can help to shape and transform the healthcare landscape and the wider mixed economy of welfare. The project has also enabled me to explore the notion of clinical governance and its constituent elements and gain insight into the importance of setting clear and explicit standards for healthcare practices and the use of evidence based management systems in order that effective, systematic measurement and evaluation at a number of levels may be accomplished. (Department of Health, 2003) In completing this exercise, it has been necessary to explore the prescribing and administration of patient medication and evaluate the activities of medical and nursing personnel within this process and so to the professional and legal

responsibilities that are an implicit element of it. (NMC, 2004) I have also reviewed a range of studies located in broadly the same subject area and took account of these in the design of the audit process itself, in addition to complying with more general guidance for best practice within a clinical audit framework (NICE, 2002). The experience has certainly made me more aware of the difficulties and errors that occur if patient prescription cards are completed incorrectly and has alerted me to best practice in this clinical area. Moreover, in undertaking the audit, I feel that I have gained both knowledge and skills that can be transferred and replicated in different settings or areas of practice. Ultimately, I have been involved in a clinical audit from its inception to completion, have drawn heavily from a range of research and theoretical material and have witnessed at first hand, some limitations and potential difficulties and also the many benefits of applying this important element of clinical governance within a variety of healthcare settings. On this basis alone, the experience has been both personally challenging and rewarding and has itself served to demystify the process of clinical audit, transforming it from a nebulous and distant concept to one that is tangible and furthermore, an entity that has clear and demonstrable value within nursing practice.

References Dean, B., Schachter, M., Vincent, C. and Barber, N. (2002). Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 359: 1373- 1378.

Department of Health, (2001). Building a Safer NHS for Patients. London: The Stationery Office. Department of Health. (2000). The NHS Plan: a plan for investment, a plan for reform. London: The Stationery Office. Department of Health. (2002). Health and Social Care (Community Health and Standards) Act 2003. London: The Stationery Office. Department of Health. (2003). Essence of Care: Patient-Focussed Benchmarks for Clinical Governance. London: The Stationery Office. Department of Health. (2004). Standards for Better Health. London: The Stationery Office. Driscoll, J. (2000). Practising Clinical Supervision: A Reflective Approach. London: Bailliere Tindall. Haw, C. and Stubbs, J. (2003). Prescribing errors detected by pharmacists at a psychiatric hospital. Pharmacy in Practice. 13: 64-66. James, A., Worrall, A. and Kendall, T. (2005). Clinical Governance in Mental Health and Learning Disability Services: A Practical Guide. London: Gaskell Press. National Health Service. (1997). The New NHS: Modern, Dependable. London: The Stationery Office. National Institute for Health and Clinical Excellence. (2002). Principles for Best Practice in Clinical Audit. Oxford: Radcliffe Medical Press. 8

NHS Executive Health Service Circular, (1999). Clinical Governance: Quality in the New NHS. London: Department of Health. Nicholls, S., Cullen, R., O’Neill, S. and Halligan, A. (2000). Clinical governance: its origins and its foundations. Clinical Performance and Quality Health Care. 8, 3, 172-178. Nursing and Midwifery Council. (2002). Guidelines for the Administration of Medicines. London: NMC. Nursing and Midwifery Council. (2004). The Nursing and Midwifery Council Code of professional conduct: standards for conduct, performance and ethics. London: NMC. Paton, C. and Gill-Banham, S. (2003). Prescribing errors in psychiatry. Psychiatric Bulletin. 27: 208-210.

Scally, G. and L. J. Donaldson. (1998). Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal. Vol. 317, 61-6 Starey, N. (2001). What is Clinical Governance? Evidence-Based Medicine. 1, 12, 18. Wilson J (1998). Incident reporting. British Journal of Nursing. Vol. 7, 11, 670-671.

Audit Tool/Checklist Patient Information 1. Is the patient's name on the prescription? 2. Is the patient's address on the prescription? 3. Is the patient's weight recorded (if relevant to the dosage)? 4. Is there a method of recording any known allergies? 5. Are all entries in indelible black ink? 6. Are all entries clearly legible? 7. Is a Mental Health Act 1983 authorisation form present? Prescription Content 1. Does the prescription give the name of the medicine? 2. Is the drug name spelt correctly? 3. Is the strength of the medicine given? 4. Is there a description of what form the medicine is in? 5. Are there full dosage instructions? 6. Does the prescription clearly state the timing of the dose? 7. Is the frequency clearly stated? 8. Is the quantity of the medicine clearly stated? 9. Is the route of admission clearly stated? 10. Is the start and finish date of treatment clearly stated? 11. Does the prescriber sign the prescription? 12. Does the prescriber date the prescription?