The Case for Change Nina Muscillo Manager Medication Safety Clinical Excellence Commission
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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 outcomes, increased readmissions and mortality3
Medication Reconciliation
• Improves communication of 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 orders 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 of 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 of 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
or 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 confirmationdocumented
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 otherdiscrepancy 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?
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