The Case for Change Nina Muscillo Manager Medication Safety - - PowerPoint PPT Presentation

The Case for Change

Nina Muscillo Manager Medication Safety Clinical Excellence Commission

Overview

• Background
• Impact on NSW patients
• Current practice in NSW

Patient Safety Problem

• Medication errors are a common clinical incident
• Around half of medication errors occur on

admission and discharge1

• Around one third of these have the potential to

cause harm2

• Often due to poor communication of medicines

information, resulting in unintentional changes

• Unintentional changes are linked to poorer health
• utcomes, increased readmissions and mortality3

Medication Reconciliation

• Improves communication
• f medicines information

at transfers of care

• 4 easy steps
• An internationally

recognised strategy

• Medication reconciliation

processes are part of the NSQHS Standards (4.6, 4.8 & 4.12)

The Literature

Admission Inpatient Discharge

10 – 67% of medication histories contain at least one error4 60 – 80% of patients had an error/discrepancy in their medication

• rders when

compared with their medication history5 12 – 80% of discharge summaries contained an error5

Transfers

‘Patients prescribed medications for chronic diseases were at risk for potentially unintentional discontinuation after hospital admission. Admission to the ICU was generally associated with an even higher risk of medication discontinuation.’7

Emergency Ward A Ward B ICU Discharge Hospital B

‘At least one in six patients have one or more clinically significant medication errors on transfer’6

Key Challenges

• No ownership
• Culture – multidisciplinary/interdisciplinary
• Documentation – not clear, buried
• Workflow – handover between teams
• Education – no mentors
• Resources / infrastructure – varies between

facilities and units

We cannot solve our problems with the same thinking we used when we created them.

• Albert Einstein

Impact on NSW patients

Examples of medication incidents at:

• Admission
• Transfer
• Discharge

There are varying degrees of patient harm that result from these incidents

Case 1: On Admission…

• An elderly patient admitted to hospital
• On admission patient was charted for clonazepam

(benzodiazepine) 5 mg daily as documented on a previous

hospital discharge summary

• The patient was normally on clonazapam 0.5 mg daily
• The 5 mg dose (ten-fold dosing error) was continued

for 2 weeks

• The patient suffered 5 falls during this time
• A family member reported that the patient was

unusually drowsy

Case 1: Continued

• The patient was then transferred to another ward and

the 5 mg dose was queried by a pharmacist. They verified the dose with the patient’s GP to be 0.5 mg daily

• A reducing regimen was required to prevent

withdrawal seizure

• It was noted that the clonazepam 5 mg dose listed on

the original discharge summary was incorrect

Case 2: On Admission…

• Elderly patient (over 90 years) was admitted

to a medical ward via the Emergency Department with atrial fibrillation

• All regular medications were prescribed
• In addition clozapine (antipsychotic used in the treatment of

schizophrenia) was prescribed in error and

administered

Case 2: Continued

• The patient suffered loss of consciousness

and was treated for a suspected stroke

• The following day the medication error was

detected

• It was noted that whilst this patient was in

the Emergency Department there was another patient admitted on clozapine

Case 3: Transfer Between Clinical Areas…

• A patient was transferred from a ward to ICU for

treatment of respiratory failure

• On transfer to ICU the patient’s regular thyroxine

was not transcribed

• On transfer back to the ward nursing staff noted

that the patient had not received thyroxine during their prolonged ICU admission

• Thyroxine was recommenced, however the

patient suffered a hypothyroid coma and required readmission to ICU

14

Case 4: Transfer Between Facilities…

• A patient was transferred between two

District Hospitals with a deep vein thrombosis

• Patient was on a treatment dose of an

anticoagulant prior to transfer

• On transfer, the anticoagulant was not

prescribed on the medication chart

Case 4: Continued

• After 18 days a doctor noted that the

anticoagulant was not prescribed

• The doctor contacted a medical officer

from the transferring facility and confirmed that the anticoagulant dose should have been continued

• Omission of the anticoagulant put the

patient at a high risk of developing pulmonary emboli

Case 5: On Discharge…

• An elderly patient discharged from hospital

to a nursing home

• The medicines listed on the discharge

summary were incorrect. Notably warfarin that had been prescribed for stroke prevention was omitted

• Patient received incorrect medicines for

seven days before the error was noticed

• The patient represented to ED following a

stroke eleven days post discharge

We cannot solve our problems with the same thinking we used when we created them.

• Albert Einstein

Current practice example

Patient presents to Emergency Department Medical history including medication history is recorded in paper or electronic notes Medication chart is written Patient admitted to ward

Patient admitted to ward

Medical Team reviews medication information from ED physician (chart and notes) Medical Team checks medication information with the patient if

• able. May ask family to bring in patients own medications from
• home. May occasionally ring GP for information

May make changes to medications directly onto medication

• chart. May record and clarify change in the progress notes

Patient admitted to ward

Medical Team reviews medication information from ED physician (chart and notes) Medical Team checks medication information with the patient if

• able. May ask family to bring in patients own medications from
• home. May occasionally ring GP for information.

May make changes to medications directly onto medication

• chart. May record and clarify change in the progress notes

Patient admitted to ward

Pharmacist may (if patient high risk) interview the patient/carer to obtain a thorough medication history. Confirming the information with at least 2 sources Pharmacists documents the medication history on the front

• f the inpatient medication chart or a dedicated form

Pharmacist reviews medication orders. Any discrepancies or issues identified are clarified with the prescriber

Patient admitted to ward

23

Pharmacist may (if patient high risk) interview the patient/carer to obtain a thorough medication history. Confirming the information with at least 2 sources Pharmacists documents the medication history on the front

• f the inpatient medication chart or a dedicated form.

Pharmacist reviews medication orders. Any discrepancies or issues identified are clarified with the prescriber

Patient admitted to ward

Nurses check medication orders prior to administering

• medications. Patients may alert nurse of a medicine not charted
• r normally taken at different time or looks different

Often the medication history and prescribing decisions are unavailable at the point of care for nurses to identify reconciliation discrepancies. Result delays and missed opportunity to capture errors

Any discrepancies or issues identified are clarified with the prescriber

Currently in NSW

52% 45% 0%

0% 20% 40% 60% 80% 100% Clear & documented < 24hrs Clear with allergy details Clear/allergies with confirmation documented

Percentage of patients with a clear medication history

Source: Random sample of 110 patient record across 3 LHDs (2 x metro, 2 x rural hospitals)

Currently in NSW

40% 27% 62%

0% 20% 40% 60% 80% 100% Omission Other discrepancy Either omission or other discrepancy or both

Percentage of patients with at least one omission or discrepancy on their discharge summary

Source: Random sample of 110 patient record across 3 LHDs (2 x metro, 2 x rural hospitals)

An accurate medication list is a key to excellent and safe care

References

1. Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. (2005). Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual 20:95-8. 2. Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, Etchells EE. (2005). Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 165:424-9. 3. Gillespie U, Alassaad A, et al. (2009). A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomised controlled trial. Arch Intern Med 169:894-900. 4. Tam V, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. (2005). Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic

• review. CMAJ 173:510-5.

5. Australian Commission on Safety and Quality in Health Care (2013). Literature review: medication safety in Australia, Sydney, ACSQHC. 6. Pronovost P, Weast B, Schwarz M, Wysiel RM, Prow D, Milanovich SN, et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. J Crit Care 2003;18:201-5. 7. Bell CM, Brener SS, Gunraj N, Huo C, Bierman AS, Scales DC, Bajcar J, Zwarenstein M, Urbach

• DR. Association of ICU or hospital admission with unintentional discontinuation of

medications for chronic diseases. JAMA 2011;306;8: 840-47

Thank you

Questions?