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Standard 4: Medication Safety

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Title: Australian Commission on Safety and Quality in Health Care Author: niall johnson Last modified by: harvef Created Date: 11/17/2002 5:15:27 PM – PowerPoint PPT presentation

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Title: Standard 4: Medication Safety


1
Standard 4Medication Safety
Graham Bedford, Margaret Duguid Accrediting
Agencies Surveyor Workshop, 11 July 2012
2
Why have a standard about medication safety?
  • Medications are the most prevalent health therapy
    in Australia
  • Estimated 1.5million adverse medicine events
    annually, resulting in at least 400,000 GP visits
    and 140,000 hospital admissions1
  • Adverse medicines events associated with2
  • 38 of readmissions to hospital
  • 33 ED attendances
  • Acute care medication errors
  • 2 5 of drug charts contain prescribing errors3
  • 5 18 of doses medicines administered in error3
  • 18 of IV infusions administered incorrectly
    (gt75 rate errors)4
  • Medication errors a major cause of patient harm
  • Errors are preventable

3
Why have a standard about medication safety?
Where do errors occur ? 5
Dispensing 11
  • Prescribing
  • 39

Administering 38
Transcription 12
52 of prescribing errors reach the patient -
Pharmacists and nurses prevent errors
Only 2 of administration errors intercepted.
4
Causes of medication errors
  • Systems failures
  • Environment
  • frequent interruptions slips, lapses
  • Insufficient information
  • Patient information, medicines information
  • Poorly written medication orders
  • Poor design of medication forms, electronic
    systems
  • Look-alike sound-alike names
  • Similar packaging
  • Poor medicines storage
  • Poor teamwork, communication with colleagues,
    patients
  • Lack of knowledge

5
Standard 4 Medication Safety
  • The Medication Safety Standard describes the
    elements of a safe medication management system.
  • It requires hospitals to have in place
    strategies and systems known to reduce the risk
    of common causes of medication error.
  • standardisation and systemisation of processes
  • improving clinical workforce and
    clinician-patient communication
  • using technology to support information recording
    and transfer
  • providing better access to patient information
    and clinical decision support at the point of
    care.

6
Standard 4 Medication Safety
  • Clinical leaders and senior managers of a health
    service organisation implement systems to reduce
    the occurrence of medication incidents, and
    improve the safety and quality of medicine use.
    Clinicians and other members of the workforce use
    the systems to safely manage medicines.
  • Two overarching Standards
  • Standard 1 Governance for Safety and Quality
  • Standard 2 Partnering with Consumers

7
Five criteria (Part 1)
  • Governance and systems for medication safety
  • Health service organisations have mechanisms for
    the safe prescribing, dispensing, supplying,
    administering, storing, manufacturing,
    compounding and monitoring of the effects of
    medicines.
  • Documentation of patient information
  • The clinical workforce accurately records a
    patients medication history and this history is
    available throughout the episode of care.
  • Medication management processes
  • The clinical workforce is supported for the
    prescribing, dispensing, supplying,
    administering, storing, manufacturing,
    compounding and monitoring of medicines.

8
Five criteria (Part 2)
  • 4. Continuity of medication management
  • The clinician provides a complete list of a
    patients medicines to the receiving clinician
    and patient when handing over care or changing
    medicines.
  • 5. Communicating with patients and carers
  • The clinical workforce informs patients about
    their options, risks and responsibilities for an
    agreed medication management plan.

9
1. Governance and systems for med safety
  • 4.1Developing and implementing governance
    arrangements and organisation policies,
    procedures and/or protocols for medication
    safety, which are consistent with national and
    jurisdictional legislative requirements, policies
    and guidelines.
  • Why?
  • Systems for safe and high quality medications
    need organisational support and executive and
    clinical leadership to be successful
  • Robust clinical governance frameworks and
    processes for evaluation, audit and feedback are
    important for the improvement of medication
    management systems.

10
1. Governance and systems for med safety
  • 4.1Developing and implementing governance
    arrangements and organisation policies,
    procedures and/or protocols for medication
    safety, which are consistent with national and
    jurisdictional legislative requirements, policies
    and guidelines.
  • What?
  • Identify suitable individual / group / committee
    to take responsibility for governance of
    medication safety system (4.1.1)
  • Drug and Therapeutics, Management Committee
  • Reporting to safety and quality governance,
    executive
  • Terms of reference could include
  • monitoring the safety and quality of medicines
    use in the facility
  • conducting interventions to improve the safety
    and quality
  • managing adverse drug reactions and medication
    incidents
  • establishing a medication safety risk register
  • informing staff about medicines use issues,
    policies etc

Consumer
11
1. Governance and systems for med safety
  • 4.1Developing and implementing governance
    arrangements (cóntd)
  • What?
  • Incorporate medication safety into strategic and
    operational plans, safety and quality risk
    registers (4.1.1)
  • Monitor the impact of interventions
  • Training programs for staff
  • Medication safety risks, strategies to reduce the
    risks
  • Staff attendance at training
  • Completing NIMC on line learning module
  • Completion of NPS medication safetymodules (in
    progress)
  • .

12
1. Governance and systems for med safety
  • 4.1Developing and implementing governance
    arrangements and organisation policies,
    procedures and/or protocols (contd)
  • What?
  • Develop and implement medication policies and
    procedures across the organisation (4.1.2)
  • Consistent with legislative requirements
  • Readily accessible, version control with review
    date
  • Examples
  • list of medicines approved for use in the
    facility (formulary)
  • prescribing policies and guidelines
  • procedures for administering medicines,
    independent checking
  • procedure for checking patient identification
  • use of the NIMC and ancillary charts
  • Audits of compliance

13
1. Governance and systems for med safety
Source. APAC Guiding principles to achieve
continuity of medication management 2005 6
14
1. Governance and systems for med safety
15
1. Governance and systems for med safety
  • 4.2 Undertaking a regular, comprehensive
    assessment of medication use systems to identify
    risks to patient safety and implementing system
    changes to address the identified risks
  • Why?
  • Evaluation of medication management systems to
    identify areas of risk, determine changes
    required and prioritise areas for improvement
  • Ongoing monitoring needed to track changes over
    time and ensure that systems operate effectively

16
1. Governance and systems for med safety
  • 4.2 Undertaking a regular, comprehensive
    assessment of medication use systems to identify
    risks to patient safety and implementing system
    changes to address the identified risks
  • What?
  • Adopt, or develop, and implement processes for
    assessing the safety of the medication system
    (4.2.1)
  • Use a structured tool e.g. Medication Safety Self
    Assessment7
  • Multidisciplinary team
  • Every three years
  • NIMC national audit
  • Failure Modes Effects Analysis

17
1. Governance and systems for med safety
  • 4.2 Undertaking a regular, comprehensive
    assessment of medication use systems to identify
    risks to patient safety and implementing system
    changes to address the identified risks
  • What?
  • Respond to assessment findings to improve
    performance (4.2.2)
  • Action plan or risk register with actions
  • Quality improvements implemented and evaluated
  • Audits
  • Indicators e.g. Indicators for Quality Use of
    Medicines in Australian Hospitals 7, State
    performance measures
  • Communication with workforce

18
1. Governance and systems for med safety
  • 4.3 Authorising the relevant clinical workforce
    to prescribe, dispense and administer medications
  • Why?
  • To ensure that only staff with the competence and
    authority to do so can prescribe, dispense and
    administer medicines
  • Staff work within their scope of practice

19
1. Governance and systems for med safety
  • 4.3 Authorising the relevant clinical workforce
    to prescribe, dispense and administer medications
  • What?
  • Develop a system to
  • identify areas where specific authorization is
    required to prescribe, dispense or administer
    medicines and
  • verify and maintain register/log of individual
    clinicians with qualifications and
    competencies(4.3.1)
  • Review the use of the system. Identify if system
    breached (4.3.2)
  • Identify actions to strengthen the system,
    address any breaches (4.3.3)

20
1. Governance and systems for med safety
  • 4.4 Using a robust organisation-wide system of
    reporting, investigating and managing change to
    respond to medication incidents
  • Why?
  • Medication incidents are the second most commonly
    reported incidents in Australian hospital
    incident monitoring systems
  • To learn about the safety of the medication
    management process by reviewing incident reports,
    analysing and investigating incidents causing, or
    with the potential to cause, patient harm.
  • See also Standard 1.14

21
1. Governance and systems for med safety
  • 4.4 Using a robust organisation-wide system of
    reporting, investigating and managing change to
    respond to medication incidents
  • What?
  • Implement a mechanism for staff to report
    medication incidents and for incidents to be
    analysed, investigated and reported to the
    medication safety governance group (4.4.1)
  • Review reports to identify trends, causes (4.4.1)
  • Involve clinical staff, medication sub-committee
  • Identify actions to reduce risk of recurrence
    (4.4.2)
  • Medication safety risk register with actions
  • Safety and/or quality improvement plan
  • Report to quality/patient safety committee
  • Feedback to staff

22
1. Governance and systems for med safety
  • 4.5 Undertaking quality improvement activities
    to enhance the safety of medicines use
  • Why?
  • To reduce harm to patients from known risks by
    implementing and measuring the effect of quality
    improvement activities outlined in the medication
    safety quality improvement plan, risk register.
  • These activities may include actions recommended
    to address risks identified from
  • Medication incident management system, RCA
    reports,
  • State, national or international medication
    safety notices/alerts,
  • Medication Safety Self Assessments
  • NIMC audit.

23
1. Governance and systems for med safety
  • 4.5 Undertaking quality improvement activities
    to enhance the safety of medicines use
  • What?
  • Assess the performance of the medication
    management system and evaluate effectiveness of
    changes (4.5.1)
  • Indicators e.g. Indicators for Quality Use of
    Medicines, state performance measures
  • IHI Global Trigger Tool (identify adverse
    medicines events and areas for improvement in the
    medication management system)
  • Auditing implementation of recommendations,
    safety alerts
  • Recommendations for labelling of injectable
    fluids, lines and medicines
  • National alerts e.g. potassium, vincristine
    alerts
  • State medication safety alerts

24
1. Governance and systems for med safety
Prescribing errors unclear, incorrect
orders Administration documentation Pharmacists
documentation
25
1. Governance and systems for med safety
  • 4.5 Undertaking quality improvement activities
    to enhance the safety of medicines use
  • What?
  • Use information from 4.5.1 to identify further
    improvement activities required to increase the
    safety and effectiveness of medicines use (4.5.2)
  • Implement recommendations/alerts
  • Standardisation of work practices and products
  • Use pre-mixed solutions or preloaded syringes for
    injectable high risk medicines
  • Standardise dosing protocols, medication checking
    procedures
  • Implement policies, procedures and workforce
    training to support standardisation
  • Use infusion pumps with IV safety software
    (smart pump technology) and drug libraries
  • Implement oral dispensers for oral liquid
    medicines

26
1. Governance and systems for med safety
27
2. Documentation of patient information
  • The clinical workforce accurately records a
    patients medication history and this history is
    available throughout the episode of care

28
2. Documentation of patient information
  • 4.6 The clinical workforce taking an accurate
    medication history when a patient presents to a
    health service organisation, or as early as
    possible in the episode of care, which is then
    available at the point of care
  • Why?
  • The medication history is used as the basis for
    therapeutic decision making, for ensuring
    continuity of regular medicines while a patient
    is in hospital and to identify adverse medicines
    events.
  • Medication histories are often incomplete (10
    67 have errors) and a cause of error and harm 9.

29
2. Documentation of patient information
  • 4.6 The clinical workforce taking an accurate
    medication history when a patient presents to a
    health service organisation, or as early as
    possible in the episode of care, which is then
    available at the point of care
  • What?
  • Clinicians document a Best Possible Medication
    History by interviewing patient/carer and
    verifying history with at least one other source.
    (4.6.1)
  • Clinicians trained in taking a BPMH
  • Standard form with prompts to elicit history
    (manual/electronic)
  • e.g. National Medication Management Plan or
    equivalent

30
2. Documentation of patient information
Clinicians can access the medication historyand
clinical information required for safe
prescribing at the point of prescribing (4.6.2)
Keep the MMP together with the current NIMC
Electronic system allows history to be viewed
when prescribing
31
2. Documentation of patient information
  • Medication Management Plan supports workforce
  • Taking a complete and accurate medication history
    (BPMH) (4.6.1)
  • Documenting ADRs on admission, if ADR occurs
    during episode of care (4.7.1)
  • Reconciling discrepancies between history and
    medication orders (4.8.1)

32
2. Documentation of patient information
  • 4.7 The clinical workforce documenting the
    patients previously known adverse drug reactions
    on initial presentation and updating this if an
    adverse reaction to a medicine occurs during the
    episode of care
  • Why?
  • Prevent avoidable harm from administration of a
    medicines to which the patient has a known
    allergy or adverse reaction
  • Communicate complete allergy/adverse drug
    reaction history to next care provider
  • Contribute to post marketing surveillance of
    medicines

33
2. Documentation of patient information
  • 4.7 The clinical workforce documenting the
    patients previously known adverse drug reactions
    on initial presentation and updating this if an
    adverse reaction to a medicine occurs during the
    episode of care
  • What?
  • Clinicians obtain and document a history of
    allergies and adverse drug reactions (ADRs) when
    patients are admitted (4.7.1)
  • Reduce risk of adverse reactions (4.7.2) by
  • Recording information on the medication chart
    (NIMC) or in electronic record - information
    available when medicines are prescribed,
    dispensed or administered
  • Updating clinical record when ADR experienced
    during episode of care
  • Informing GP and patient in discharge
    documentation
  • Monitoring documentation through audits,
    indicators (Indicator 3.2 Indicators for QUM in
    Australian Hospitals)

34
2. Documentation of patient information
  • 4.7 The clinical workforce documenting the
    patients previously known adverse drug reactions
    (contd)
  • What?
  • System encourages and supports clinicians to
    report adverse reactions
  • Within in organisation for consideration by the
    Medication Safety Governance Group
  • Review ADRs reported and feedback information to
    staff in medication safety or drug bulletins, at
    staff in-service session, grand rounds
  • To Therapeutic Goods Administration (4.7.3)
  • Facility to report ADRs to TGA online
  • Number of ADRs reported to TGA

35
2. Documentation of patient information
  • 4.8 The clinical workforce reviewing the
    patients current medication orders against their
    medication history and prescribers medication
    plan, and reconciling any discrepancies
    (Developmental)
  • Why?
  • Studies show that 30 70 patients admitted to
    hospitals have 1 discrepancy between medicines
    taken at home and medicines ordered on admission
    10
  • The process of reconciling medicines ordered with
    the medication history (BPMH) reduces by gt50 the
    errors and adverse events that occur when care is
    transferred e.g. when patient admitted,
    transferred internally or discharged

36
2. Documentation of patient information
  • 4.8 The clinical workforce reconciling
    discrepancies between patients current
    medication orders and medication history
  • What?
  • Implement a formal structured process to ensure
    all patients admitted to the health service
    receive accurate and timely medication
    reconciliation at admission, transfer of care and
    on discharge. (4.8.1)
  • Procedures assigning responsibilities
  • Training staff
  • Using a standard form to document medicines
    reconciled
  • National Medication Management Plan, equiv or
    e-version
  • NIMC Medicines taken prior to presentation
    section
  • Prioritise patients gt65 years, multiple
    medicines/morbidities, high risk medicines if
    resources limited
  • Audits of rate and quality of reconciliation

37
2. Documentation of patient information
MATCH UP Medicines Resources
  • . . .

2. Documentation of patient information
Medication Management Plan implementation
resources
37
38
3. Medication management processes
  • The clinical workforce is supported for the
    prescribing, administering, storing,
    manufacturing, compounding and monitoring of
    medicines

39
3. Medication management processes
  • 2.9 Ensuring that current and accurate medicines
    information and decision support tools are
    readily available to the clinical workforce when
    making clinical decisions related to medicines
    use
  • Why?
  • Lack of knowledge about medicines, lack of access
    to up to date protocols/guidelines are factors
    known to contribute to medication errors and
    harm.
  • The availability of decision support tools when
    medicines are prescribed, dispensed and
    administered improves the safety and quality of
    medicines use.

40
3. Medication management processes
  • 4.9 Ensuring that current and accurate medicines
    information and decision support tools are
    readily available (contd)
  • What?
  • Implement and maintain up-to-date medicines
    information resources and decision support tools
    (manual or electronic) that are accessible to
    staff in clinical areas (at point of care)
    (4.9.1)
  • formulary information, prescribing requirements,
    approval systems
  • reference texts
  • policies, protocols and guidelines
  • dosing calculators
  • drug interaction databases
  • guidelines for safe administration of specific
    medicines (eg administering medicines via enteral
    tubes)
  • antibiotic approval systems

41
3. Medication management processes

SHPA Australian Injectable Drugs Handbook SHPA
Dont Rush to Crush Handbook
Hospital protocols, guidelines
42
3. Medication management processes
  • 4.9 Ensuring that current and accurate medicines
    information and decision support tools are
    readily available (contd)
  • What?
  • Regular review of the use and content of clinical
    information and decision support tools, to ensure
    that resources are current, and are endorsed for
    use within the organisation (4.9.2)
  • Drug Therapeutics Committee minutes/documentatio
    n
  • Risk assessment of drug information domain in
    MSSA
  • Take action to improve clinical information and
    decision support tools where a need is identified
    based on review (4.9.3)
  • Drug Therapeutics Committee minutes
  • Examples of improvements

43
3. Medication management processes
  • 4.10 Ensuring that medicines are distributed and
    stored securely, safely and in accordance with
    the manufacturers directions, legislation,
    jurisdictional orders and operational directives
  • Why?
  • Product integrity is maintained, medicines stored
    safely, and waste minimised
  • Distribution systems are responsive to clinical
    demand in order for medicines to be available for
    patient care in a timely manner.

44
3. Medication management processes
  • 4.10 Ensuring that medicines are distributed and
    stored securely, safely (contd)
  • What?
  • Regular review and risk assessment of medicines
    storage and distribution across the
    organisation.(4.10.1)
  • As part of overall self assessment
  • Audit against policies, procedures
  • Observation audits and walk arounds
  • Review medication incidents

45
3. Medication management processes
  • 4.10 Ensuring that medicines are distributed and
    stored securely, safely (Contd)
  • What?
  • Actions to reduce risks (including confusion with
    look alike sound alike names) (4.10.2)
  • Policies and procedures
  • Safe handling and disposal of S8 medicines,
    cytotoxic products and hazardous substances
  • Use of bar code scanners (dispensing,
    distribution)
  • Physical separation of products (e.g. look-alike,
    sound-alike products)
  • Use of Tall Man lettering (e-systems, infusion
    pump libraries, shelving, packaging)
  • Purchasing for safety
  • Safer distribution systems
  • Staff communication, alerts,
  • bulletins

46
3. Medication management processes
  • 4.10 Ensuring that medicines are distributed and
    stored securely, safely (contd)
  • What?
  • Temperature sensitive medicines are monitored and
    integrity of temperature-sensitive medicines
    maintained (4.10.3)
  • Temperatures measured, recorded, reviewed
  • Workforce disposes of unused, unwanted or expired
    medicines, in accordance with legislative and
    jurisdictional requirements (4.10.4)
  • S8 medicines audits
  • Disposal of cytotoxic products and hazardous
    substances (WHS issues)
  • Monitoring disposal of unused, unwanted or
    expired medicines (4.10.5)
  • Compliance with policy for disposal
  • Wastage

47
3. Medication management processes
  • 4.11 Identifying high risk medicines in the
    organisation and ensuring they are stored,
    prescribed, dispensed and administered safely
  • High risk medicines - PINCH (Potassium, Insulin,
    Narcotics(S8s),Chemotherapy, Heparin
    (anticoagulants)
  • What?
  • Undertake an assessment of how high risk
    medicines are managed within the organisation
    (4.11.1)
  • audits
  • incident analysis
  • risk assessment tools
  • drug usage evaluation programs
  • collaborative projects
  • benchmarking activities.

48
3. Medication management processes
  • 4.11 Identifying high risk medicines in the
    organisation and ensuring they are stored,
    prescribed, dispensed and administered safely

49
3. Medication management processes
Audits of compliance
50
3. Medication management processes
  • 4.11 Identifying high risk medicines in the
    organisation and ensuring they are stored,
    prescribed, dispensed and administered safely
  • What?
  • Put systems in place to minimise the risk of
    error (4.11.2)
  • List of high risk medicines available to staff
  • Policies, procedures and protocols
  • Guidelines for prescribing, dispensing,
    administering and monitoring specific high risk
    medicines such as anticoagulants, chemotherapy,
    opioids, insulin
  • Pre-loaded infusions potassium, heparin
  • Training on awareness of high risk meds
  • Implement safety alerts on high risk medicines
  • Monitor improvement activities

51
4. Continuity of medication management
  • 4.12 Ensuring a current comprehensive list of
    medicines, and the reason(s) for any change, is
    provided to the receiving clinician and the
    patient during any clinical handovers
  • Why?
  • 60 of patients have 3 changes during their
    hospital stay 11
  • Adverse drug events occur in up to 20 after
    discharge 11
  • Patients with 1 medicine left off their
    discharge summary are 2.3 times more likely to be
    readmitted 12
  • Providing an accurate list of current medicines
    at handover decreases medication errors and
    adverse events

52
4. Continuity of medication management
  • 4.12 Ensuring a current comprehensive list of
    medicines, and the reason(s) for any change, is
    provided to the receiving clinician and the
    patient during any clinical handovers
  • What?
  • Implement and maintain a system that supports
    clinicians to generate accurate and comprehensive
    medicines lists and explanations for changes when
    transferring care (4.12.1)
  • Policies and procedures for medicines handover
  • Process of reconciling medicines list with
    medication history (BPMH), discharge medicines
    dispensed and current medication orders (on
    medication chart)
  • Audit of discharge summaries that include
    medicines list, reasons for any changes

53
4. Continuity of medication management
  • 4.12 Ensuring a current comprehensive list of
    medicines, and the reason(s) for any change, is
    provided to the receiving clinician and the
    patient during any clinical handovers
  • What?
  • List of medicines to be continued on discharge
    along with explanations of changes provided to
  • Patient / carer (with counselling)(4.12.2)
  • Audit clinical records (pharmacy)
  • Receiving clinician (4.12.3)
  • Audit of discharge summaries that include
    medicines list, reasons for any changes
  • Use of MMP and NIMC at internal transfer

54
4. Continuity of medication management
  • 4.12 Ensuring a current comprehensive list of
    medicines, and the reason(s) for any change, is
    provided to the receiving clinician and the
    patient during any clinical handovers
  • What?
  • Increase number of patients and receiving
    clinicians provided with a current list when care
    transferred (4.12.4)
  • Communication to staff, patients

5.3 Percentage of discharge summaries that
include medication therapy changes and
explanations for changes
55
5. Communicating with patients and carers
  • The clinical workforce informs patients about
    their options, risks and responsibilities for an
    agreed medication management plan.
  • Developmental

56
5. Communicating with patients and carers
  • 4.13 The clinical workforce informing patients
    and carers about medication treatment options,
    benefits and associated risks
  • Why?
  • Patients and carers require sufficient
    information about treatment options to make
    informed choices about their medicines, and
    adhere to agreed treatment plans
  • Failure to achieve informed agreement to the
    prescription can result in non-adherence

57
5. Communicating with patients and carers
  • 4.13 The clinical workforce informing patients
    and carers about medication treatment options,
    benefits and associated risks
  • What?
  • Implement systems that support the provision of
    patient specific medicines information when
    medication treatment options are discussed
    (4.13.1)
  • Consumer Medicines Information provided
    (documented on MMP, in clinical notes)
  • Consumer information on specific medications, for
    example anticoagulants, chemotherapy
  • Patient specific medicines information accessible
    in clinical areas (4.13.2)
  • Hard copy or soft copy

58
5. Communicating with patients and carers
  • 4.14 Developing a medication management plan in
    partnership with patients and carers
  • Why?
  • 30 50 medicines prescribed for long term
    conditions not used as prescribed 11
  • Failure to achieve informed agreement or
    identify and provide support that patient needs
    to manage their medicines can lead to
    non-adherence can occur 11
  • The medication management (action) plan is
    intended to support health professionals and
    patients/carers in developing strategies to
    manage medicines safely and achieve treatment
    goals

59
5. Communicating with patients and carers
  • 4.14 Developing a medication management plan in
    partnership with patients and carers
  • What?
  • Undertake assessment of the patients medication
    risks to identify medication management issues
  • Use Medication Risk Identification section on
    National Medication Management Plan
  • Develop a medication management (action) plan
    that establishes treatment goals and specifies
    actions required to achieve medication management
    goals (4.14.1).
  • List of medicines, allergies, administration aids
  • Goals of therapy, action to achieve goals
  • Communicate plan to patient and with the
    patients consent to other relevant health care
    professionals

60
5. Communicating with patients and carers
  • 4.15 Providing current medicines information to
    patients in a format that meets their needs
    whenever new medicines are prescribed or
    dispensed
  • Why?
  • Patients and carers require information in a form
    they understand and can use to assist them to use
    their medicines safely and effectively

61
5. Communicating with patients and carers
  • 4.15 Providing current medicines information to
    patients in a format that meets their needs
    whenever new medicines are prescribed or
    dispensed
  • What?
  • Identify medicines information resources that are
    in a format that can be used and understood by
    patients and carers when new medicines are
    prescribed/supplied or medicines changed(4.15.1)
  • Similar evidence to 4.14.3
  • Interpreter services available for CALD patients
  • Written information in patients own language e.g.
    multilingual medicines lists
  • Improve medicines information provided in
    response to patient feedback (4.15.2)
  • Action in response for complaints, patient survey

62
Communicating with patients and carers
63
Resources
  • Australian Commission on Safety and Quality in
    Health Care Medication Safety
    http//www.safetyandquality.gov.au/our-work/medica
    tion-safety/
  • State and Territory Medication Safety
    Committees/sites
  • Clinical Excellence Commission High risk
    medicines program
  • http//www.cec.health.nsw.gov.au/programs/high-ris
    k-medicines
  • New South Wales Health Medication Management
    Strategy
  • http//www.health.nsw.gov.au/quality/medsafe/index
    .asp
  • Victorian Health Department Quality Use of
    Medicines
  • http//www.health.vic.gov.au/qum/index.htm
  • Western Australian Department of Health
    Medication Safety
  • http//www.safetyandquality.health.wa.gov.au/medic
    ation/index.cfm

64
Resources
  • Audit, indicators and assessment tools
  • Canadian Patient Safety Institute. Safer
    Healthcare Now! Medication reconciliation
    Measures
  • www.saferhealthcarenow.ca/EN/Interventions/medrec/
    Pages/measurement.aspx
  • Clinical Excellence Commission, NSW Therapeutic
    Advisory Group Inc. Medication Safety Self
    Assessment for Australian Hospitals, 2007.
    www.mssa.cec.health.nsw.gov.au/MSSA_introduction.h
    tml
  • Clinical Excellence Commission, NSW Therapeutic
    Advisory Group Inc Medication Safety Self
    Assessment for Antithrombotic Therapy in
    Australian Hospitals. www.mssa.cec.health.nsw.gov.
    au/at2/MSSAT_introduction.html
  • Continuity in Medication Management a Handbook
    for South Australian Hospitals November 2010.
    Appendix 3 SA APAC Key Performance Indicators.
  • www.sahealth.sa.gov.au/wps/wcm/connect/e055bd8044f
    d8fc2aff7efcfa5ded0ab/PharmaceuticalReformHandbo
    okV7_Printversion.pdf?MODAJPERESCACHEIDe055bd
    8044fd8fc2aff7efcfa5ded0ab
  • Institute for healthcare Improvement Failure
    Modes and Effects Analysis Template
  • http//app.ihi.org/Workspace/tools/fmea/

65
Resources
  • Audit, indicators and assessment tools (Contd)
  • ISMP Canada International Medication Safety Self
    Assessment for Oncology 2012 www.cec.health.nsw.go
    v.au/programs/mssa
  • NSW TAG. Indicators for Quality Use of Medicines
    in Australian Hospitals www.ciap.health.nsw.gov.au
    /nswtag/documents/publications/QUMIndicators/Manua
    l0408.pdf
  • SQuIRe Plus Guide Medication Reconciliation
    Audit Tool January 2012 www.safetyandquality.healt
    h.wa.gov.au/docs/squire/Medication_Reconciliation_
    Audit_Tool_Guidelines.pdf
  • Patient and carer tools and resources
  • ACSQHC Medication reconciliation consumer
    resources.
  • http//www.safetyandquality.gov.au/our-work/medica
    tion-safety/
  • Institute of Safe Medication Practices Consumer
    website
  • www.ismp.org/consumers/default.asp,
    www.consumermedsafety.org
  • NPS Better Choices, Better Health. Medicines
    information for consumers
  • http//www.nps.org.au/consumers.
  • WA Health Consumers Council Patient First Guide
    (March 2012)
  • http//www.health.wa.gov.au/docreg/education/popul
    ation/OA004305_patient_first_book.pdf
  •  

66
Resources
  • Education resources
  • ACSQHC Medication Management Plan Flash training
    tool with audio voice over
  • hwww.safetyandquality.gov.au/our-work/medication-s
    afety/medication-reconciliation/nmmp/
  • http//whqlibdoc.who.int/publications/2011/9789241
    501958_eng.pdf
  • National Inpatient Chart On- line Training Course
    www.nps.org.au/health_professionals/online_learni
    ng/NIMC
  • NPS Better Choices Better Health National
    Prescribing Curriculum on line training
    www.nps.org.au/health_professionals/online_learnin
    g/national_prescribing_curriculum
  • NPS, NSW TAG Medication Safety e-Learning
    Modules
  • http//www.nps.org.au/health_professionals/online_
    learning
  • NPS Better Choices, Better Health Quality use of
    medicines on line training courses
  • http//www.nps.org.au/health_professionals/online_
    learning/qum
  • World Health Organization. Improving Medication
    Safety. WHO Patient Safety Curriculum Guide
    Multiprofessional Edition, 2011.
    http//www.who.int/patientsafety/education/curricu
    lum/en/index.html

67
Summary
  • Ensuring that competent clinicians safety
    prescribe, dispense and administer appropriate
    medicines to informed patients and carers is an
    essential element of safe and high quality care.
  • Purpose of the Standard is to improve outcomes
    for patients by ensuring that there is a
    systematic approach to medicines management and
    safety
  • Outcomes to be achieved are clear methods to
    get there will vary depending on context
  • www.safetyandquality.gov.au
  • margaret.duguid_at_safetyandquality.gov.au

68
Summary
  • Ensuring that competent clinicians safety
    prescribe, dispense and administer appropriate
    medicines to informed patients and carers is an
    essential element of safe and high quality care.
  • Purpose of the Standard is to improve outcomes
    for patients by ensuring that there is a
    systematic approach to medicines management and
    safety
  • Outcomes to be achieved are clear methods to
    get there will vary depending on context
  • www.safetyandquality.gov.au
  • margaret.duguid_at_safetyandquality.gov.au

69
References
  • Roughead EE Lexchin A. Adverse Drug Events
    counting is not enough, action is needed. Medical
    Journal of Australia2006184(7)315-6
  • Easton K, Morgan T, Williamson M. Medication
    safety in the community A review of the
    literature. National Prescribing Service, June
    2009
  • Australian Council for Safety and Quality in
    Health care. Second national Report of Patient
    Safety Improving Medication Safety. Canberra
    2002
  • Roughead EE, Semple SJ Medication safety in acute
    care in Australia where are we now?. Part 1 a
    review of the extent and causes of medication
    problems 2002-2008 ANZ Health Policy 2009, 618
  • Leape L et al Systems analysis of adverse drug
    events JAMA 199527135-43
  • Australian Pharmaceutical Advisory Council.
    Guiding principles to achieve continuity of
    medication management .2005
  • Clinical Excellence Commission, NSW Therapeutic
    Advisory Group Inc. Medication Safety Self
    Assessment for Australian Hospitals, 2007.
    www.mssa.cec.health.nsw.gov.au/MSSA_introduction.h
    tml
  • NSW TAG. Indicators for Quality Use of Medicines
    in Australian Hospitals www.ciap.health.nsw.gov.au
    /nswtag/documents/publications/QUMIndicators/Manua
    l0408.pdf
  • Tam V, Knowles S, Cornish P, Fine N, Marchesano
    R, Etchells E. Frequency, type and clinical
    importance of medication history errors at
    admission to hospital a systematic review. CMAJ
    2005173(5)510-15.
  • NICE. Technical patient safety solutions for
    medicines reconciliation on admission of adults
    to hospital. London. National Institute for
    health and Clinical Excellence, 2007.
  • NICE. Medicines adherence involinmg patients in
    decisions about prescribed medicines and
    supporting adherence Clinical Guideline CG 76
    January 2009
  • Stowasser DA, Stowasser M, Collins DM. A
    randomsied controlled trial of medication liaison
    services patient outcomes. J Pharmacy Practice
    and Research 200232133-40
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