Margaret Duguid, Pharmaceutical Advisor Graham Bedford, Medication Safety Program Director

1. Standard 4 Medication Safety Medication Safety Standard 4Part 3 – Documentation of Patient Information , Continuity of Medication Management Margaret Duguid, Pharmaceutical Advisor Graham Bedford, Medication Safety Program Director

2. 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

3. 2. Documentation of patient information Criterion: Documentation of patient information

4. 2. Documentation of patient information Standard 4 Medication Safety 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

5. 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

6. 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 risk medicines if resources limited Audits of rate and quality of reconciliation Standard 4 Medication Safety

7. 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. 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

8. 2. Documentation of patient information Standard 4 Medication Safety 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.

9. 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@safetyandquality.gov.au 2. Documentation of patient information Standard 4 Medication Safety

10. Standard 4 Medication Safety 2. Documentation of patient information • Medication reconciliation resources • www.safetyandquality.gov.au/our-work/medication-safety/medication-reconciliation/ 2. Documentation of patient information Medication Management Plan + implementation resources 10

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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.

17. 4. Continuity of medication management Standard 4 Medication Safety 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.

18. 4. Continuity of medication management Standard 4 Medication Safety 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“ patients.

19. 4. Continuity of medication management Standard 4 Medication Safety 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.

20. 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.

21. 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.

22. Standard 4 Medication Safety Australian Commission on Safety and Quality in Health Care Medication Safety Program www.safetyandquality.gov.au Email mail@safetyandquality.gov.au margaret.duguid@safetyandquality.gov.au