Following feedback from service users, Verity Miles, Head of Healthcare, and her colleagues at HMP High Down started a project to improve medication administration by reducing the number of missing medications on House Block 6. They also produced an excellent Quality Improvement (QI) poster about this project that won an Improvement Academy Award in 2022.

HMP High Down is currently a category B remand prison in Sutton and medication is administered across 8 areas. However, it was noted that some medication is not available on any given house block at the time when it is prescribed to be given. This caused dissatisfaction with patients as they were missing their doses leading to some patients also becoming verbally abusive toward healthcare staff.

HMP High Down medication cabinets.jpgTo improve this, the team did a review of the medication administration process to understand the process from beginning to end and discover what could be improved.

They felt that an efficient medication administration process will lead to a safer and more reliable process, improve patient satisfaction and give nursing and pharmacy staff more time to perform other clinical duties.

The project aim was to:

  • achieve a 20% reduction in missing meds on House Block 6 (HB6) by June 2022
  • increase the number of Patients on In-Possession (IP) Meds
  • reduce the time required to complete meds administration on the House Blocks
  • improve patient and staff experience of the process

Missing medication reports were run using DATIX and through Pharmacy using a detailed form which allows reprinting of the prescription and reducing delay of medication to patients. Pharmacy would then collate all missing medication data and add information to Life QI on a weekly basis. New medication cabinets were also installed and tested to see if they reduce the instances of missing meds.

The outcome was positive with patients and staff noticing an improvement in reduction of missing medication, less abuse from patients and better overall medication administration process. This is what some of them had to say:

“I am happy to go back to In-Possession meds now because it seems like meds can be found easier and not many people are being told their meds aren’t there” - Patient on HB6

“I like the new cupboards, I really do, they are so much better. You can see everything for each patient and all their meds stay together in a single line in boxes with ‘In-Possession’ (IP) meds at the back – The new Alphabetical order is far easier “- House Block Registered Nurse