Transcript PowerPoint, 4MB - Australian Commission on Safety and Quality in

Medication Safety Standard 4
Part 3 – Documentation of Patient
Information , Continuity of Medication
Management
Margaret Duguid, Pharmaceutical Advisor
Graham Bedford, Medication Safety Program Director
Standard 4
Medication
Safety
2. Documentation of patient information
The clinical workforce accurately records a patient’s
medication history and this history is available throughout
the episode of care
Standard 4
Medication
Safety
2. Documentation of patient information
Criterion: Documentation of patient information
2. Documentation of patient information
4.6.1 A best possible medication history is documented for each patient
Q. How will accrediting agencies judge whether or not
medication histories taken are accurate?

A. Clinical records, NIMC, Medication Management Plan
• Education and training in taking BPMH
• Medication reconciliation process in place
• Audit of admission histories
– Can be done during Medication Reconciliation process
Standard 4
Medication
Safety
2. Documentation of patient information
4.7.1 Known medication allergies and ADRS are documented in the
patient clinical record
Q. Do you need to document all ADR information on all medication
charts ?
A. NIMC is “Source of truth” for ADRs
• Cross reference other charts to NIMC
• E.g. Specialist charts, clozapine, heparin
• Electronic health record (EHR)
• One source of information in EHR
• Active transfer information to e- medication management system,
pharmacy system
• Display on prescribing screen
• Use active alerts in e- prescribing and dispensing systems Standard 4
Medication
Safety
2. Documentation of patient information
4.8 The clinical workforce reconciling discrepancies between patient’s
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 or e-version
- NIMC Medicines taken prior to presentation section
• Prioritise patients >65 years, multiple medicines/morbidities, high
Standard 4
risk medicines if resources limited
Medication
• Audits of rate and quality of reconciliation
Safety
2. Documentation of patient information
4.8.1 Current medicines are documented and reconciled at admission and
transfer of care
Q. Who can document history, reconcile medicines?
A. Health professionals trained to reconcile medicines
- Nurses, doctors, pharmacists, pharmacy technicians
• Nurse:Pharmacist model
- Nurse consults with pharmacists on discrepancies
Q. Major gaps exist around provision of medication
reconciliation
A. Prioritise to patients at higher risk
• Take a multidisciplinary approach
- Assign responsibilities at W/Es, after hours
Standard 4
Medication
Safety
2. Documentation of patient information
4.8.1 Current medicines are documented and reconciled at admission and
transfer of care

Q. Where histories are recorded electronically, and this is used to
facilitate continuity of care through discharge, must facility have
computers on wheels to comply with point of care requirement

A. Facility should work out the best work flow that facilitates
availability of the BPMH when discharge summary and prescription
are being prepared.

Q. What is medication management plan, where is it available from?

A. The medication management plan is a form for documenting and
reconciling medication histories on admission. It is available from
the Commission website.
Standard 4
Medication
Safety
2. Documentation of patient information
Medication Management Plan
supports workforce to:
Take
and record a complete and
accurate medication history (BPMH)
(4.6.1)
Document
ADRs on admission (4.7.1)
Reconcile
discrepancies between
history and medication orders (4.8.1)
Design files available from Commission
[email protected]
Standard 4
Medication
Safety
2. Documentation of patient information
Medication reconciliation resources
www.safetyandquality.gov.au/our-work/medication-safety/medicationreconciliation/
2. Documentation of patient information
Medication Management Plan
+ implementation resources
Standard 4
Medication
10
Safety
4. Continuity of medication management

The clinician provides a complete list of a patient’s
medicines to the receiving clinician and patient when
handing over care or changing medicines.
Standard 4
Medication
Safety
4. Continuity of medication management
4.12: Ensuring a current comprehensive list of medicines, and 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
• Electronic or paper based system for communicating current
medicines (list), changes – internal transfer, discharge
• Audit of discharge summaries that include medicines,
reasons for any changes
4. Continuity of medication management
4.12: Ensuring a current comprehensive list of medicines, and 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 along with explanations of changes
provided on intra-, inter- transfer and discharge.
Intra- or inter- hospitals
• Electronic systems
• Paper based – Use MMP and NIMC
Discharge
• Process for reconciling medicines list (patients and discharge summary)
with medication history (BPMH), discharge medicines dispensed and
current medication orders (on medication chart)
• Patient / carer (with counselling)(4.12.2)
- Audit clinical records (pharmacy)
• Receiving clinician (4.12.3)
- Audit of discharge summaries that include list of medicines, reasons for
any changes
4. Continuity of medication management
4.12: Ensuring a current comprehensive list of medicines, and 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)
-
Audit, monitor indicators
Identify gaps in practice
Practice improvement activities
Communication to staff, patients
5.3 Percentage of discharge summaries that include
medication therapy changes and explanations for
changes
4. Continuity of medication management
4.12 Current, comprehensive list of medicines provided to receiving clinician
and patient at clinical handover
Q. Does 4.12. apply to outpatients ?
A. Referring doctor must be informed of changes to medicines. Patient
informed of changes, patients own list amended.
Q. Patient admitted for operation e.g. eye, ear op. No changes are made to
their medicines apart for eye drops/medicines associated with the
surgery. Do they need a comprehensive list of medicines supplied?
A. Yes. A comprehensive list should be supplied.
4. Continuity of medication management
Issues in rural sector
Q. Who reconciles the patients medicines on discharge ?
A. Where admitting doctor is the patient’s GP who is looking after the
patient throughout the episode of care and in the community, there is no
handover of care to another clinician and risk for error is low. In this
case, the GP should reconcile the patient’s medicines on discharge.
Where the person discharging the patient is handing over the patient to
another clinician then the reconciliation can be done by anyone trained
to reconcile medicines - nurse, pharmacist or medical officer. Patients
can be prioritised according to their risk and health services need to
work out a process that works for their situation.
4. Continuity of medication management
Issues in rural sector
Q. Do hospitals need to generate a comprehensive discharge summary
when the patient’s GP is looking after the patient during their admission?
A. The medicines the patient is to continue on post discharge must be
recorded in the patient’s hospital medical record. Where there are
changes made during the admission this information must be
communicated to the GP’s practice to ensure that they update their
records with any changes.
Standard 4
Medication
Safety
4. Continuity of medication management
Issues in rural sector
Q. Who generates the patients medicines list when there is no pharmacist
at the hospital?
A. There are different models for patients medicines lists.

GP generating the list from their software, either in the hospital (if
software available) or in the surgery and patients collects on way
home/next day.

Where the patient has an existing medicines list and there are no
changes they can continue to use their current list

Community pharmacy producing a list from the reconciled discharge
summary/list. There is also the Medscheck program for "at risk“
Standard 4
patients.
Medication
Safety
4. Continuity of medication management
Issues in rural sector.
Q. There are IT programs that can be used to generate a medicines list.
Can nurses use these programs to generate the list and ask the GP at
the hospitals to check if it is correct?
A. Nurses trained to reconcile medicines on admission and discharge can
generate a medication list using an existing IT program. Queensland
Health Enterprise wide Liaison Medication System ( ELMS) program is
an example.
Standard 4
Medication
Safety
4. Continuity of medication management
4.12: Ensuring a current comprehensive list of medicines, and reason(s) for any change, is
provided to the receiving clinician and the patient during any clinical handovers

Q. How can medicines be build into clinical handover in hospital,
especially high risk medicine e.g. shift to shift handover ?

A. Standards 4 and 6 are clear about medicines being in handover.
Item 4.12 requires that current medicines and changes are
communicated at clinical handover. The MMP and NIMC can be
used as tools to assist in handover.

It is not necessary for all medicines to be discussed at shift to shift
handover but important medicines information, including information
on high risk drugs, instructions re changes, medicines to be ceased
must be included. Medicines should be a standard item in handover
protocols. Do a local risk assessment to determine what to include
in the handover.
Standard 4
Medication
Safety
4. Continuity of medication management
4.12: Ensuring a current comprehensive list of medicines, and reason(s) for any change, is
provided to the receiving clinician and the patient during any clinical handovers

Q. For clinical handover within the hospital (e.g. transfer to imaging)
is transferring patient’s NIMC sufficient to meet this criteria?

A. As discussed re shift to shift handover information, the NIMC can
be used but there should also be some verbal discussion about
critical, high risk medicines.

Q. Does 4.12.3 relate to this type of handover or does it specifically
relate to transfer of care between treating teams?

A. Yes it does relate to that type of handover and is especially
important when transferring between levels of care when the risk of
error is high.
Standard 4
Medication
Safety
Australian Commission on Safety and Quality
in Health Care
Medication Safety Program
www.safetyandquality.gov.au
Email [email protected]
[email protected]
Standard 4
Medication
Safety