These Sort of Baby Steps Just Drive Me Crazy. We Can Do Heaps Better Than This.

The following press release appeared a few days ago

Improving patient medication safety in Australia World Health Organization’s High 5s Project

PDF printable version of Improving patient medication safety in Australia World Health Organization’s High 5s Project (PDF 43 KB)

20 April 2010

Today, the Australian Commission on Safety and Quality in Health Care (ACSQHC) has, with the participation of 28 hospitals across Australia, launched a program to improve the safety of patients receiving medicines in hospitals.

Under the program, the participating hospitals will introduce standardised procedures to collect and check information about each patient’s medicines much more rigorously and accurately, starting from when the patient is first admitted to hospital and continuing through each stage of the patient’s hospital treatment when medicines may change.

The procedures are also designed to make sure that when the patient is finally discharged, they and their doctor will also get an accurate and comprehensive list of the medicines they may need to take once they are back in the community.

Professor Chris Baggoley, the ACSQHC Chief Executive, said, ‘At the moment, we know that the information hospitals collect about patients’ medicines may be incomplete, and that important medication information can become disjointed as patients are transferred within a hospital.’

‘Errors creep in that can harm the patients. Medication errors are a major problem for hospitals worldwide. Australia and many other developed countries report that adverse medicines events are a leading cause of error, injury and death within their healthcare systems’ Professor Baggoley said.

‘Evidence suggests that a formal procedure for checking and reconciling medication information in hospitals is effective in reducing adverse medicines events as patients move from one stage of care to another.’

Hospitals will start implementing and evaluating the standardised procedures in high risk areas, beginning with patients 65 years and older who are admitted through the emergency ward to inpatient services. Subsequent phases will include all patients at all entry points and all transitions in care. ‘This process aligns with Australia’s National Medicines Policy and will improve patient safety’, Professor Baggoley said.

The Australian Commission on Safety and Quality in Health Care (the Commission) is the lead technical agency for Australia, coordinating and supporting participating hospitals and monitoring outcomes.

The initiative is part of a World Health Organization campaign to improve patient safety. Other countries participating in the initiative are Canada, the Netherlands, France, Germany and the United States.

The new standardised procedures lay out a systematic process for obtaining, at the time of admission, a complete and accurate list of each patient’s current medications – including name, dosage, frequency and route; using the list when writing admission, transfer or discharge medication orders; and comparing the list against the patient’s admission, transfer and discharge orders, identifying and bringing any discrepancies to the attention of the prescriber and, if appropriate, making changes to the orders.

For further information, please visit the Medication Safety Program page (under ‘Our Work’) at www.safetyandquality.gov.au or contact the Commission on (02) 9263 3633

The release is found here:

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/MediaRelease_2010-04-20_Hi5s

Why, might you ask is David grumpy when this sort of stuff comes up?

Let me make a few points.

First, I would have thought it was incumbent on any clinician to show extreme diligence in getting an accurate picture of a patient’s current medications – both clinician and self prescribed. This is not even best practice – it should be basic standard practice and if it is not this initiative has a far more basic problem to address – called ‘clinician slackness’.

Second the other issue (communication between different places and branches of an organisation) would be much better addressed not by extra elaborate handover rules but by the use of electronic medical records that have the medications the patient is receiving driven by that record on an hour by hour basis. I.e. it is accurate because it is what is driving medication delivery and issues at an point are then picked up virtually as they happen.

Take it from me nurses are very good at picking up that a medication is being missed or overdone etc as they are the ones actually giving the medicines to the patient!

Third it is also meant to be standard practice to review and document discharge medications on discharge. This not being done is even optional – it is, and has been mandatory –since Adam was a boy.

What is going on here is pretending some rules – and not doing some major efforts in e-Health will make patients safer.

Just nonsense and totally lacking any vision.

David.