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Keeping sight of the small things

Conferences are great opportunities to sit back and think about what we do. I recently chaired some of the sessions at the NiP London conference, and was lucky enough to listen to the session on inhaler techniques for patients with asthma and COPD. It was a fascinating reminder of the need to pay as much attention to how we deliver care as to what care we prescribe.

The session focused on our role as healthcare educators in helping our patients understand how to use the devices, so as to ensure that the prescribed inhaled drug is administered in the right way. I now understand that air propelled medication needs to be shaken because the treatment is an emulsion that requires mixing; and that powder medications should be sharply inhaled while air propelled medications should be breathed in slowly, etc. Medication that is not administered correctly is far less effective.

I will freely admit that my knowledge of asthma is paltry (apart from the fact that a member of my family is asthmatic) so I probably had a steeper learning curve than most of the audience. However, the session got me thinking about attention to detail in the delivery of other healthcare interventions. I am notoriously obsessed by leg ulcer care and one of the challenges in my field is the correct application of compression bandaging.

It's great when the aetiology of an uncomplicated venous leg ulcer is correctly diagnosed and compression bandaging is correctly prescribed. It is heartbreaking when asked to visit the patient because the wound is not healing to see that the bandaging has been applied incorrectly. At best, the patient will be receiving suboptimal care. At worst, the patient may be receiving dangerous care.

After the asthma session I was discussing this issue with colleagues and one of them told me a horror story about a patient whose medication was about to be increased because it appeared to be ineffective.

Each week the local pharmacist delivered a blister pack of medication to the patient but no one actually checked whether the patient was taking the medication. Fortunately, an astute community nurse decided to investigate and found 10 unopened blister packs in a cupboard in the kitchen.

My colleagues suggested that a simple way to reduce the risk of such situations would be if the pharmacist was to collect the previous week's empty blister pack when issuing the new one. Checking what is actually happening, rather than just assuming all is well, is so important.

Such attention to detail is essential in our work but so difficult to achieve in our frenetic working lives. However, we must keep sight of the small details that underpin the clinical care of our patients and make sure that we use systematic approaches that reduce the risks of errors. So often, when things go wrong it is not because someone has made an obvious error but that a small series of mistakes has been missed by a succession of busy clinicians.

Your comments (terms and conditions apply):

"My mother in law has dementia, not formally diagnosed as it would distress her too much according to my husband and his sister. This in itself raises all sorts of other problems. However her short term memory has really deteriorated, yet when asked questions by people generally she sounds believable, and not too confused at all. But if you were to ask her the same set of questions again she would give you totally different answers. We have been using dosette boxes for her medication for some years now, though one day we went round to pick her up for lunch with us and found the whole weeks medication in one glass. Fortunately she had not taken any, my husband now delivers it daily in a single dosette box pushed through the letter box each day before he goes on to work; he then phones her to remind her to take them, he makes sure mum checks the container with the day of the week on. He visits 4 times per week to spend time with her and she comes to dinner on Sundays. My long winded point is how many others are like this where it is not picked up, and suffer the consequences of either under or over medication. My mother in law is lucky because she has a good family network around her, so many do not" - Christine Cowlard, Surrey

"Stock piling is more common than we think. Polypharmacy does not help either. Medications are not taken when patients do not know why it is prescribed and they continued with repeat to give the impression that they are taking the medications. I have come across many patients who admit to
not taking the medications and they do not want to upset the doctors! Some just do not like taking medications and will not do so despite explaining the reason for the prescriptions. The other problem despite giving them blister packs is that they do not remember to take the medications. This area of care certainly needs to be monitored" - Nee Juan Gibson, Surrey