Transcript Medication Safety Self Assessment (MSSA) for Australian

The Medication Safety Self
Assessment (MSSA) for Australian
Hospitals
1st Survey @ Kyneton District Health
August 2013
What is the MSSA?
• Clinical Excellence Commission
• Web-based survey tool
• allows self assessment of the medication safety
practices within a hospital
• Heighten awareness of the distinguishing
characteristics of a safe hospital medication system
• 10 Key Elements, 20 Core Characteristics
• 247 questions
• create a baseline of Australian hospital efforts to
enhance medication safety
• identification of improvement opportunities and
comparison with the aggregate experience of
demographically similar hospitals (based on bed
size/public/independent governance/general medical
& surgical
service/maternity/ENT/paediatrics/rural/internal
clinical pharmacy service).
• Completed by miniMAC working party
Results: individual
Results: similar demographics
Quality Improvement Plan
• Chose items where we scored C or below
A= No Activity to implement
B= Considered but not implemented
C= Partially implemented in some or all areas
• 30 targeted actions identified for Quality
Improvement off this survey.
• Re-survey every 2 years.
Standard 4 Medication safety - governance and systems for medication safety
4.2 MSSA AUDIT August 2013 ACTION PLAN
Safety Issue Identified + Date
Action Required
July 2013. VicTAG Safety notice –
Neuromuscular Blocking Agents.
Discuss at MAC
Order warning stickers as per alert
Take to UCC working Party for
review of current NMBs in UCC &
imprest stock of Suxamethonium in
Acute.
Neuromuscular blocking agents are not
available as ward or imprest stock and/or in
automated dispensing cabinets (except in
operating room/anesthesia stock). If available in
critical care units and/or the emergency
department, neuromuscular blocking agents are
sequestered from other ward or imprest stock
medications (including those stocked in
automated dispensing cabinets) and labelled
with auxiliary warnings to clearly identify the
drugs as respiratory paralysing agents that
require mechanical ventilation when used.
Responsibility +
Timeframe
Di- by end
September 2013
Implementation Progress + Date
Started 24/7/13
Draft to miniMAC 19/9/13
-need to expand on feedback & how that works
through VHIMS.
-new classification of incidents by Standard?
-running reports?
Discussed @ MAC 4th July.
Sticker – listed on Baypac, not listed CH2
18/7/13 Stickers ordered from Baypac, sent to
UCCWP agenda, red syringes placed with stock of
Sux in Acute & UCC fridge.
Stickers obtained 25/7/13.
Discussed at UCCWP 8/8/13. Decision to remove
all imprest stock except for Theatre.
Recommendation made to UCCAC and MAC.
Decision revised by MAC, stock of sux to stay in
UCC.
Safety Notice published in Acute Newsletter
13/9/13, with advice of removal of sux from Acute
& availability of red syringes.
10/8/13 from MSSA audit
Need to update CPG on Medication Incident
Reporting.
A clear definition and examples of medication
errors and hazardous situations that should be
reported have been established and
disseminated to PRACTITIONERS.
Reportable events include both hazardous
situations that could lead to an error and actual
errors including those that have been detected
and corrected before they reach a patient.
Update CPG with VHIMS process.
Education to staff once CPG finalised.
Di – by October
2013
Before a decision is made to add a drug to the
formulary, the potential for error with that drug is
investigated in the literature, documented in the
drug monograph submitted to the MAC and
addressed.
To be included in New Formulary
Drug Submission Form.
Di – October
2013