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Using technology in care homes – eMAR

October 22, 2019 By Steve Turner

Introduction

Medicines errors in care homes are unacceptably high. A key study found that residents taking 7 or more medicines had a 79% chance of being a victim of a medicines error (Alldred et all 2009).

Slide1

Best practice in medicines record keeping

The management of medicines in nursing and residential homes is part of a highly complex pathway.  It involves multiple staff groups and organisations.

These include the G.P.; all who prescribe medicines and treatments; Care Staff of all grades; Support Workers; Consultants: Specialist Practitioners; and the Pharmacies who supply the medicines.

Benefits of electronic MAR charts

The benefits of implementing electronic MAR charts fall into three categories.

  1. Improved legibility.
  2. Improved access (e.g. if the charts are accessed and updated on a computer or portable device there is less risk of losing, damaging or mislaying them).
  3. eMAR chart systems that obtain the data taken directly from the Community Pharmacy system eliminate the need for transcribing, which is a high-risk area.

In addition to the three benefits mentioned, carefully planned and implemented eMAR systems contribute to a decrease in medicines errors, reduced administrative costs and improved quality of care.

Challenges of implementing electronic MAR charts

There are three ‘bottom line’ challenges to manage when transitioning to electronic MAR charts.

1. Assessing the way the system works is critical, as poorly designed will not deliver benefits, and eventually fail.

The system must be easy to use and jargon-free; using only approved acronyms or mnemonics.

Electronic systems also offer the opportunity to introduce features that enhance safety, some of which, such as time-ordered charts, are difficult to include in a paper-based system.

Here’s a checklist:

Slide2
Slide3

2. It is vital that the system handles patient consent; patient confidentiality, system access; ownership of patient identifiable data; storage and transfer of data in a way which is compliant with the laws and regulations of your part of the U.K. This is an important question for you to pose to the supplier, particularly with the advent of General Data Protection Regulation (GDPR),  and the new Data Protection Act 2018.

Slide4

3. It is important to look at current processes and how the new system will work. There been problems where acute prescriptions were needed and supplied by a different pharmacy from the one providing the MAR charts, so the home ended up at times with an electronic MAR and a paper MAR. This causes confusion and increases the risk of errors and/or omissions. Colleagues have told me of instances where this has led to eMAR systems being abandoned.

Training and support requirements

Quality training and support, both during the implementation and on an ongoing basis, underpin all successful healthcare I.T systems and need to be planned from the outset. There are four areas that are sometimes overlooked, that deserve special mention.

1.  Many of the users of eMAR systems will be Healthcare Assistants or other non-registered skilled staff. As a result, it will be important that the training they receive reinforces their duty to keep accurate records, and their accountability and role is made clear.

2. A significant number of staff may speak English as a second language. Therefore it is important that eMAR systems do not use any unnecessary jargon, and that any help text is in plain language.

3. Appropriate knowledge of Data Protection (GDPR) and Information Governance Rules and regulations are essential and should be built in to any training programmes.

Overall, consideration needs to be given to the nature and content of the training needed to implement the system, including how this is linked to the policies and procedures and overall governance of the home.

Good suppliers will be able to give advice and support on this.

Conclusion

Record keeping in medicines management is a critical safety area for care homes. The Senior Care Authority: Employee Assistance Solutions for Eldercare says that it is a crucial task for the staff. The current high level of medicines errors is in care homes affects half a million people in England.

The prospect of implementing electronic systems for recording medicines administration holds great potential but is not itself without risk. It needs to be approached carefully in the light of the complex arrangements and multiple organisations involved in prescribing, supplying, administering and monitoring medicines in care homes.

In time, electronic systems will become the norm for medicines management in care homes.

Given the considerations over choice and implementation of systems, eMAR can overcome problems of legibility, transcribing, and access to records and information in a way that is not possible with paper systems.

In years to come it is likely that, just as most G.P.’s would not want to return to paper systems, care homes will come to see electronic systems in the same way. The main beneficiary from this will be the residents in terms of improved safety.

This, in turn, will benefit care home staff who will no longer be involved in the risky business of sorting out, transcribing and chasing paper records. Care home providers will also benefit through decreased indirect costs associated with more efficient and safer processes.

Reference: Alldred P, Barber N, Buckle P et al (2009) Care home use of medicines study (CHUMS): Medication errors in nursing and residential care homes – prevalence, consequences, causes, and solutions. Report to the Patient Safety Research Portfolio. Department of Health, London.
 Steve Turner is Information Governance Lead and Data Protection Officer
for CareMeds Ltd

Author: Steve Turner

Date: 22.10.2019

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Filed Under: Care Homes, Care Right Now, Elderly care, Medicines, Medicines Optimisation, MEDSINFO, NHS, Uncategorized

‘I don’t want to hear anything bad’ – whistleblowing in health & social care.

August 15, 2019 By Steve Turner

Exposing the reality behind the spin

Summary

I am a healthcare professional, a nurse prescriber with experience in senior management in both the NHS and private sectors. I work as a clinician with vulnerable adults on the margins of society.

Over the past ten years I’ve become involved with a situation I was previously unaware of. The widespread marginalisation and victimisation of health and care staff who raise concerns about patient safety, and lose their careers as a result. I’ve learned that this problem is part of a much bigger picture which affects all of society, all industries and public sectors, in all countries of the world.

In this blog I reflect on the situation in England based on my experiences and those of the many people I have met as a result. All of whom experienced the backlash that can happen when organisational reputation trumps patient safety. One thing many of us have in common is that, put simply, we never intended to become known as ‘whistleblowers’ we were just trying to do our job to the best of our ability.

In conclusion, I look at key areas to be worked on in order to protect the public and really ‘learn lessons’. These cross all sectors and areas of work. They include the need for an individual duty of candour (duty to tell the truth); an end to self-regulation in healthcare and elsewhere, and recognition of the value to society of those who risk everything to fight for justice and truth.

My pledge

A dawning realisation

I began to realise something was seriously wrong when I returned to clinical work in 2002. Having previously worked in senior management (as Head of I.T. in an NHS Trust) and management consultancy, I became concerned that my employer appeared to be putting reputation over patient safety, and if concerns were raised, they were not followed up. I recall looking at Board papers and directions to trusts from the Department of Health [DH] to try and understand this further. One thing I remember is a letter to Chief Executives from the DH which talked about creating an ‘outward-facing’ organisation. I didn’t realise at the time, what I now see as the real meaning of this, and its link to the ‘no bad news culture’. This involves putting reputation above patient safety.

Later I tried to raise my concerns with a Trust Executive at an early stage, only to be told in both words and body language that the trust didn’t want to hear anything bad. This attitude, and what I saw happening to the team and staff around me, led me to leave the NHS and become self-employed working for the NHS on projects related to medicines and prescribing. Eventually my experiences led me to make a protected disclosure in 2014 , in which I set out the patient safety concerns. As a result, the CQC requested an external investigation of my concerns in 2014.

Since being interviewed for the investigation report in 2014 I have heard nothing further.  I never saw the investigation report and was never contacted about it. A freedom of information [FOI] request to the CQC produced the response that my concerns were dismissed as ‘all third hand’ (which is incorrect) and I was told that the CQC had ‘lost the report’.

Prior to the FOI request, I was employed as a CQC Specialist Advisor (a zero-hours contract), however following the FOI request this contract was ended without a specific reason being given.

The wider picture in healthcare

I’ve only briefly mentioned some of the aspects of my story here. The most important thing for me was that I found out the common themes behind all genuine healthcare whistleblowers’ stories.

Three things stand out for me.

1. The psychological effect on the whistleblower

I experienced the isolation that whistleblowers are subjected to and the psychological effect this has on individuals. Suddenly you’re on your own, and people you worked with avoid you. In my case, I also kept my distance from some co-workers, as I realised they were being bullied as a result of supporting me.

For me (now self-employed) offers of work dried up and a real feeling of being ‘sent to Coventry’ set in. In addition to the loss of income, this isolation has a deep effect on my mental health and home life. I believe the approach of employers here is called ‘gaslighting’. It’s deeply troubling.

2. The NHS cold shoulder / being blacklisted

Secondly, I have discovered through meeting other whistleblowers that blacklisting of those who speak out is very common. This can take many forms, ranging from informal blacklisting, to interventions to prevent career development, to giving unsolicited (and unfair) bad references.

For those employed by the NHS the Electronic Staff Record [ESR], which is shared throughout the NHS can be used as a way of sharing detrimental information on whistleblowers. This has caused people to be denied a fair chance to gain further employment. I believe the full extent of this is yet to come to light.

In my case the blacklisting takes the form of repeatedly being given the  ‘cold shoulder’ for example being excluded from meetings; uninvited for regular meetings I was previously part of (without a reason being given); letters and emails not replied to and generally avoided. Of course, this is subjective, and maybe sometimes I’m wrong, as healthcare is a tough work environment. However, I have been subject to some clear examples of ongoing detriment.

On one occasion my company was enthusiastically awarded a contract of work one day, then the very next day the same person ‘phoned me and cancelled the order saying only that it ‘wasn’t what they wanted’.  Very strange. Also I found out that staff from the trust I worked for were told not to speak to me, even though in one case it was to ask me a question about my clinical work.

In addition, I was deeply upset when the NHS Trust, who commissioned one of my projects, failed to acknowledge its success. A poster was presented at the NICE Conference in 2015 and it was highly commended by NICE.

Prior to the Conference, I contacted the trust to let them know of the success and all attempts to engage the trust were ignored. As you can see in the poster (which was produced by NICE) the space for the trust’s logo, on the bottom left, is empty:

In fact, I have several examples of work on the NICE Shared Learning pages, none of which have ever been acknowledged in any way by local NHS Trusts, or any healthcare organisations, in Cornwall.

Click here for the link to a recent Shared learning example Patient Led Clinical Medicines Reviews. This project also was presented live at the NICE Conference in Manchester in 2019.

3. The effect that the victimisation of healthcare whistleblowers has on patients

Thirdly, as I looked further into the problem, I began to see the full impact that the victimisation of genuine healthcare whistleblowers has on patients. This for me is the most shocking aspect of the problem.

In 2015 I set up the Turn up the Volume! Movement. This is an attempt to bring together all involved in an open and transparent way, with a focus on the core issue of patient safety.

Through this initiative I have met many more people in a similar situation and learned first-hand the effect lack of transparency and denial has on patients. This is well illustrated, for example, in the report of the Gosport Independent Panel Report (2018), where those who raised the alarm were initially listened to, then ignored and their concerns re-labelled as ‘allegations’. As a result of this, in the words of the report, ‘the lives of over 450 patients were shortened while in the hospital’.

90 second #vlog

Next steps

Based on my experience in trying to link together people in health and care with similar experiences and focus on patients, I believe there are three vitally important areas in healthcare that need addressing.

The need for an individual duty of candour

Firstly, I was shocked to find out that in the NHS the duty of candour (duty to tell the truth), brought in following the Mid Staffordshire inquiry, is an institutional duty of candour. This relies on staff telling the truth to their employer in order to highlight what went wrong.  Thanks to the tireless work of campaigner Will Powell the need for an individual legal duty of candour for professionals, managers & leaders in healthcare has been demonstrated. This has parallels to the calls for a ‘Hillsborough Law’. Without this, there is no real mechanism to hold individuals to account for cover-ups and for not being honest.

Making sure initiatives are effective

Secondly, I’m disappointed at the failure to learn and improve patient safety through listening to genuine whistleblowers, whether they be patents or staff, and failure to take measurable actions to change. I believe the effect of the National Freedom to Speak Up Guardian programme needs a full independent review (from outside the NHS). Evidence suggests it is making the situation worse in some trusts, where it is used as a cover for continued victimisation of those who speak out.

Ending self-regulation

Thirdly, in common with industry, I firmly believe that self-regulation in health and care does not work and the only solution will be to set up a truly independent body to oversee and enforce this. This body must include patients, who raise concerns at great cost to themselves and their families, against all the odds, often when people have suffered and died.

Health regulators in England and the people who they regulate are often uncomfortably close. For example, I was deeply disappointed when I found out only that the CQC Inspector involved in dealing with my concerns raised in 2013, later became employed as Compliance Lead in the same trust.

A missed opportunity

You can comment on the issues raised in this blog here: https://www.pslhub.org/forums/topic/113-blacklisting-by-the-nhsit-never-ends/

Author: Steve Turner.  Date: 15th August 2019. Revised 29th August 2019. Revised 1st September 2019, to add an outline list of the concerns I raised in 2013. Short video added 05.09.2019.

Updated 13.01.2020 with some more detail on the nature of the blacklisting.

Updated on 11.05.2020 with more examples of the ‘NHS cold shoulder’.

Updated: 11.08.2020 with link to comment via the Patient Safety learning Hub

Updated: 30.09.2021 minor changes to wording to bring the blog up to date.

Steve Turner RGN; RMN: Ba(Hons); P.G. Dip. Ed, is co-creator of patient led education, Head of Medicines and Prescribing for #MedLearn, tweeting as @MedicineGovSte , and Associate Lecturer at Plymouth University.

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Filed Under: Care Right Now, Human Factors, Leadership in Health, NHS, Organisational Culture, Transparency, Uncategorized, whistleblowing, Workshops Tagged With: #tutvlondon, accountability, health, just culture, leadership, NHS, socialcare, transparency, whistleblower, whistleblowing

Is this the profile of a healthcare radical or a troublemaker?

October 12, 2017 By Steve Turner

Steve Turner career and experience:

I began my professional career as a nurse in 1984, eventually specialising in mental health.

I spent a decade working on clinical systems for American giant Shared Medical Systems, progressing from project manager to Senior Strategic Services Consultant of the U.S. arm of the company.

In 1999 I returned to work for the NHS, successfully revamping the Information and Technology department at an NHS Trust prior to a trust merger. A spell in consultancy for a large Cancer Network followed, by leading two highly successful multi-organisational projects.

More recently I have led a successful interdisciplinary, multi-organisational prescribing project and the development of a parent held medicines record for children with complex conditions. My Associates and I have also developed, and successfully piloted, ‘patient led clinical medicines reviews’.

In 2015, after a difficult whistleblowing experience, I founded the Turn Up The Volume! movement and speak out for patient safety through transparency, values based leadership and a just culture. (www.tutv.org.uk).

We have held two successful national events, bringing together people from all areas in an atmosphere of trust and learning.


Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University  and former NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s tweets @MedicineGovSte  


 

  • Looking for someone who can engage people across boundaries? I’m available to speak at events and as a commentator

Steve Turner  RGN; RMN; Ba (Hons); P.G. Dip. Ed.

 

steve@carerightnow.co.uk

Date: 18.11.2019

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Filed Under: Care Right Now, Children Health, Elderly care, Leadership in Health, Medicines Optimisation, NHS, NICE, Organisational Culture, Prescribing, Substance Misuse, Transparency, Uncategorized, whistleblowing, Workshops

Multi-morbidity & polypharmacy (taking 4 or more meds.)

May 15, 2017 By Steve Turner

Multi-morbidity and polypharmacy (that’s taking four or more medicines)

Taken from NICE Key Therapeutic Topics  pages 5-10.

Key points:

  • People with multiple illnesses are often prescribed multiple medicines, with new medicines being added to counter side-effects of others. The actual benefits of doing this are hard to ascertain.

Taking multiple medicines involves increased risks.

  • Everyone with multiple illnesses should receive a holistic person-centred review of their medicines and share in the decision making of what they take. (My view takes this further. I’d say ‘be given the option to lead on the decision making of what they take’).
  • Polypharmacy (taking four or more medicines) can be divided into two categories. Appropriate polypharmacy, where the benefits and disadvantages have been fully evaluated together. Problematic polypharmacy, where this hasn’t been done and the benefits of the medicines are not realised, sometimes to the extent that they are making the person worse.
  • There are some useful tools which can be used to help evaluate appropriateness of medicines in individuals (described in the document). Additionally I’d add that motivational interviewing techniques and time to build trust of the patients are also vital.
  • Intentional non-adherence can be overcome in a trusting clinician patient relationship, which usually happens over time.

#jargonbuster ‘intentional non-adherence’ = not telling clinical staff what you are actually taking and/or not taking.


More on the NICE Key Therapeutics Document here:


Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed; MIHM

Steve is a nurse prescriber and NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s tweets @SteveMedGov

Steve is an Ambassador for @MedicineGov

Posting on #mentalhealth #MedsOpt #MedLearn #NICEGuidance #PatientEducation #substancemisuse #selfcare #prescribing 

Search under #MedLearn

LinkedIn profile here: https://www.linkedin.com/in/sjturner/

For more on Care Right Now’s Patient Led Clinical Education work-streams click here: https://www.carerightnow.co.uk/projects/

‘Phone 01872 248327

Or email steve@carerightnow.co.uk

 

For part one of this blog ‘Medicines are overused’ click on the image below:


 

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Filed Under: Academic Detailing, Elderly care, Jargon Buster, Medicines, Medicines Optimisation, NHS, NICE, Prescribing

Changing mindsets and delivering safe care in Cornwall together. #devocornwall

March 20, 2017 By Steve Turner

We want the best health care system in the world, & the most efficient and effective system …

We have an opportunity to do things differently in Cornwall

How do we achieve this?

 

The challenges in Cornwall

There’s a huge amount going on with health and social care in Cornwall. Including the Sustainability and Transformation Plan [STP]; exposure of abuse and neglect in care homes; concerns over hospital closures, delayed discharges taking up hospital beds, and devolution of services on the way.

Although I have worked in health and care for over 30 years, I struggle to keep up with the issues and understand how services are organised.  This isn’t helped by the current polarisation of views.

On the one hand we have a big dose of NHS and Council ‘spin’, excessive bureaucracy and even bullying. On the other hand we have public concern, often expressed around specific issues, and sometimes based on unfounded rumours.

Neither of these positions are helpful, and neither represent the vast majority of people (public, staff and patients) who just want good services delivered by kind people who are open, accountable and transparent.

#devocornwall

We have a great opportunity now with the devolution of health and care services. This will be realised if we all build bridges, and transcend the usual hierarchical boundaries. We all need to listen and learn. Everyone, to coin an overused phrase, needs to step out of their comfort zones.

Why we need to think differently?

Several community hospitals are under threat of closure, leading to anger and dominating the headlines. Less attention is given to identifying and measuring the benefits, and any disadvantages of community hospitals. For example, can they be staffed adequately, bearing in mind this means Doctors, Nurses, Physiotherapists, Radiographers, Dieticians, Speech and Language Therapists, Social Workers etc.? Is home care a viable option for patients and carers?  Are there any creative options such as bringing back the old style ‘convalescence’? Is rural isolation and lack of public transport the major issue?

It’s becoming increasingly difficult to book a timely GP consultation. This has led to several inaccurate scare stories in the press about ‘cuts’ to face to face GP contacts. This needs deep thought as there are times when easy access to a GP on the ‘phone, or on-line, may actually be a better option. Access to health information from Community Pharmacies or in NHS run clinics in shopping centres, or better health information and advice available locally, may be more effective approach. Leaving GPs free to spend more time with those who need their help and expertise most.

It’s now widely accepted that the NHS and Social Care is underfunded. Despite this there is still a great deal of duplication and waste in the system. How many times have you been asked to repeat information to Health Professionals which others already have? Do some services overlap, and are there gaps? Do different organisations link seamlessly with other organisations? Are all services accessible to all? Many people have important stories to tell on these areas of inefficiency.

Now’s the time to talk about this, find out what’s planned, and take action together. ‘Patient engagement’ key component of the STP and #devcornwall.

Patients and public need to take the lead on this. It’s not the NHS or Cornwall Council’s plan it’s ours.

Personal views of Steve Turner. MD Care Right Now CIC, a Cornish Company

Version 2

Date: 30/03/2017

This article is adapted from a letter which fist appeared in the St Austell Voice

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Filed Under: Care Homes, Care Right Now, Children Health, CIC, Elderly care, Human Factors, Jargon Buster, Leadership in Health, Medicines Optimisation, NHS, Organisational Culture, Transparency, Uncategorized, whistleblowing

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