Process-mapping the DMT Pathway to maximise patient safety
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In September 2021 I started in a newly created post as an MS pharmacist. One of the initial priorities for my role, identified by one of the consultants, was to be responsible for the monitoring of Tecfidera patients and the maintenance of the Tecfidera patient database, as this had been done by admin staff to date.
Whilst screening a Tecfidera prescription, I found the patient’s lymphocyte count to be low, so looked to see what her previous result had been, to establish whether this was a new incident (so needing close monitoring) or a continuing trend (which may lead to treatment cessation).
I found that the patient was not on our database, and we had no blood results for her since starting treatment. As a lot of our patients are out-of-area and have their blood tests performed at their GP practice, there was certainly a chance that this patient had been having the required blood tests, but they had not been uploaded onto our system. Unfortunately, it transpired that the patient had not had any blood tests since starting treatment nearly a year previously, so the decision was made to stop treatment and get urgent blood tests.
A Datix report was made about this incident, and I was asked to investigate this to identify why blood monitoring was not done, and to prevent this from happening again in the future. I process-mapped the pathway undertaken when this patient was started on Tecfidera, and compared this with the ideal process that should be followed. By identifying gaps in the process, we can make changes to mitigate these. It is important to learn from incidents such as these, to make the systems in place stronger and safer, rather than assuming that they are a one-off incident.
By changing the way we communicate with, and deliver important information to, patients, as well as making the best use of staff members available, we hope to have mitigated some of these risks.
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