Medicine handling
- barriers against errors

Facts

Project title
Medicine handling - barriers against errors
Collaboration partner
Invia – Syddansk Sundhedsinnovation, Kolding Hospital Paediatrics Ward P12 og P3
Period
2011 - 2012
Topics
User-driven innovation, health innovation, welfare design, service design, design process
Project Management
Design School Kolding

Medicine handling
- barriers against errors

Inappropriate medication is a large problem within the Danish healthcare system. The purpose of the project "Medicine handling - barriers against errors" was to create better preconditions for proper and safe medicine handling at Kolding Hospital.

Inappropriate medication constitutes 34 % of all unintended incidents at the Danish hospitals and causes 70,000-160,000 hospitalisations annually. 3 % of these leads to deaths.

8-15 % of all hospitalisations are due to inapproriate medicine or inappropriate handling of medicine. Approximately half of these hospitalisations could have been prevented. In addition, inappropriate medication costs society around DKK 4-8 billions annually. So it makes perfect sense - both in terms of people and money - to bring down the number of inappropriate medication cases at the hospitals. 

Objective
The overall objective of "Medicine handling - barriers against errors" was to ensure that the right patient received the right medicine in the right dosage at the right time via the right line of authority. 

In addition, the project focused on the work culture and the work procedures that characterise hospital staff's handling of medicine.

Mobile iPad stand which guides staff on how to handle different types of medicine and clinical guidelines.
The iPad stand is mobile and can be moved around. Apart from videos the stand contains steel trays that can be used as a work desk, a cannula container and a waste basket.
The campaign "Thank you for the time" ("Tak for tiden") makes the staff aware not to disturb or interrupt each other unless it is very urgent as this can lead to errors.
A small pamphlet with an "interruption barometer" which helps the staff to stop and think before interrupting or disturbing one another.
The book "With Rumle at the Paediatrics Ward" ("Med Rumle på Børneafdelingen") which is given to all children who are admitted to the Paediatrics Award at Hospital Lillebælt.
Checklist for doctors
Checklist for doctors and nurses

Results

The project resulted in four suggestions for barriers against errors. Four specific design solutions in the form of new products, processes and policies that supplement each other and therefore constitute a holistic solution:

  • iPad stand for nurses
  • Checklists for doctors and nurses
  • Awareness campaign "Thank you for the time" ("Tak for tiden")
  • Patient book "With Rumle at the Paediatrics Ward" ("Med Rumle på Børneafdelingen")

The Kolding Hospital Paediatrics Ward won the Region of Southern Denmark Work Environment Award 2012 for its attention to work interruptions; a focus that took its point of departure in the awareness campaign "Thank you for the time" ("Tak for tiden") that was developed during the project.

Method

The medicine handling project focused on P12 og P3, the Paediatrics Ward at Kolding Hospital. This was the first ward of its kind to make a targeted effort to further patient safety for children in Denmark.

The success criteria for the project was to reduce the number of unintended incidents related to medication at Kolding Hospital and to share the solutions with paediatrics wards around the country.

Design School Kolding and Invia – Syddansk Sundhedsinnovation chose a "barrier against errors" approach. The solutions are based on a human factor perspective which means that all aspects related to making errors have been considered. User-inclusion has been a key element of the project.

Download the project report (in Danish)

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