Background A patient’s suicide attempt with benzodiazepines was reported to our quality department. The patient ingested a bottle of drops given for his weekend leave. According to French regulations, patients are allowed to leave hospital for at most 48 hours but administratively they are still hospitalised and under the director’s responsibility. Their medicines must be provided for this period.
Purpose To assess the therapeutic management of patients on weekend leave in order to highlight opportunities for improvement.
Materials and Methods We performed an audit of the medical management of patients on weekend leave. The audit was performed using a form containing open questions. One nurse from each department was audited.
Results Although nurses can’t refer to any procedures on this topic, all care units provide medicines by strictly following the prescription. Multidose vials (drops, syrups, etc.) are not unpacked and are given in their entirety. One care unit out of nine mentioned that patients are stated to be on leave in the patient’s medical record. Only 22% of audited nurses systematically put the treatment in a pillbox. Several nurses reported that pillboxes weren’t available which resulted in treatments being bulk packed in a bag by 66% of wards or in a plastic pot by 11%. 56% of treatments were delivered with the care plan coming from the patient record.
Conclusions The audit highlighted the need to standardise practises (traceability, packaging of treatment and the presence of a care plan) and improve safety, to purchase daily pillboxes for all wards and to solve technical problems for delivering multidose medicines.
The pharmacy, in cooperation with the quality department, wrote a procedure in order to refocus the medical management of patients going on leave. The pharmacy is now responsible for delivering oral syringes for drinkable solutions in order to prevent such an accident from happening again, by delivering the exact amount prescribed.
No conflict of interest.
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