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Chapter 3
A National Programme for the Improved Management of
Medications
Scoping the Priorities for Quality in the Health and Disability Sector
Introduction
This chapter discusses the process and programme to be implemented in the
NZ health and disability sector to improve the management of medications
provided to consumers/patients over the next two years.
Definitions used Medication reconciliation
in this chapter
A process for reconciling the difference between a record of a patient’s
medications and their actual medications.
Collaborative also known as a Breakthrough Series1
An improvement method that works with multiple teams to achieve
significant change over many sites over a short period of time
Medication error
A medication error may be defined as any error that occurs in the medication
process. Medication errors often do not result in harm.2
Adverse drug event
An adverse drug event (ADE) may be defined as ‘any injury due to a
medication.’ This injury may be due to the wrong dose of a medication (over
or under dose), the wrong medication being given, or given to the wrong
person, or the medication being given by the wrong route (e.g. intrathecal
instead of intravenous).3 An adverse drug event can result from an error of
omission or commission.
Adverse drug reaction (ADR)
Any response to a drug which is noxious, unintended and occurs at doses
normally used for prophylaxis, diagnosis or therapy. 4 Adverse drug reactions
are a subset of ADEs
Medication/medicine
A product is a medicine if it has a pharmacological effect and it is used in
humans primarily for a therapeutic purpose.5
Quality use of medicines
The safe, effective and appropriate use of medicines.6
1
Institute for Healthcare Improvement. (1995) www.ihi.com
SUM Group (2005) Safe and Quality Use of Medicines National Strategy
3
SUM Group (2005) Safe and Quality Use of Medicines National Strategy
4
World Health Organisation (2002) Safety of Medicines: A guide to detecting and reporting adverse drug reactions.
http://www.who.int/medicines/library/qsm/who-edm-qsm-2002-2/esd_safety.pdf
5
SUM Group (2005) Safe and Quality Use of Medicines National Strategy
6
SUM Group (2005) Safe and Quality Use of Medicines National Strategy
2
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Background
Why is this
priority
important?
“Medicine safety is an important area by virtue of the fact that medicines are
one of the commonest therapeutic interventions used in the healthcare system.
The sheer scale of medicines usage means that any major reduction or
prevention of adverse drug events holds the prospect of a substantially safer
health system for everyone.”7
Medication errors in hospitals are common.8 9 Approximately 1% of people
admitted to hospital may experience a significant medication error and up to
5-7% of the remaining admissions will suffer less severe outcomes for a
medication error.10 Many of these errors are preventable. Health systems
across the western world have implemented various improvement strategies
over recent years to reduce the rate of medication errors, thereby reducing the
harm that is caused to patients in the care.
Effective and safe medication management or quality use of medicines
includes a consideration of the appropriateness of the medications prescribed,
the correct dispensing and administration and the provision of accurate and
appropriate information. The implementation of better systems for managing
medications includes education and training, implementing improved
processes for prescribing, dispensing and administering medicines and the
implementation of technological solutions that assist providers to make fewer
mistakes and to dispense the correct dose of the correct medicine, to the
correct person, via the correct route and at the correct time.
The process by which drugs are administered to patients has multiple steps.
At every step in the process there is the opportunity for a mistake to occur
The medication management cycle consists of:11
1. a decision on appropriate treatment
2. decision to prescribe medicine
3. record of medicine order/prescription
4. review of medicine order/prescription
5. issue of medicine
6. provision of medicine information
7. distribution and storage
8. administration of medicine
9. monitor for response
10. transfer of verified information
The challenge is to make fundamental systemic change and improvement in
the way that care is delivered to patients.
7
SUM Group (2005) Safe and Quality Use of Medicines National Strategy
Brennan, Leape, Laird et al (1991) Incidence of adverse events and negligence in hospitalised patients. Results of
the Harvard Medical Practice Study I NEJM
9
Bates, Cullen, Laird et al (1995) Incidence of adverse drug events and potential adverse drug events. Implications
for prevention. JAMA
10
SUM Group (2005) Safe and Quality Use of Medicines National Strategy
11
Australian Pharmaceutical Advisory Council (2005) Guiding principles to achieve continuity in medication
management.
8
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Progress in the New Zealand Health and Disability Sector,
Introduction
A coordinated approach to medication management in New Zealand health
and disability services has been “on the radar” for several years. The
following information is provided from the Safe and Quality Use of
Medicines National Strategy that was published in September 2005.
Policy
directives or
strategies to
date
The District Health Boards New Zealand (DHBNZ) Chief Executives Group
established the Safe Use of Medicines (SUM) Group in April 2003 as a
collaborative venture between the District Health Board’s. This group
organised the Medication Safety and Quality Use of Medicines in New
Zealand Workshop in May 2004 both to inform people about the projects the
group were working on and to determine the way forward for the group. The
delegates at the workshop provided a clear mandate to the group to include
quality use of medicines in its focus. The group as a result became the
DHBNZ Safe and Quality Use of Medicines Group (SQM).
This safe and quality use of medicines strategy covers activities in both
primary and secondary care. It has been designed to provide both a national
framework and the national co-ordination of activities to improve medicine
related outcomes and to encourage consistency and effectiveness of, and
participation in safe and quality use of medicines activities whilst reducing
duplication of effort.
Key features of the Safe and Quality Use of Medicines strategy are:
1. Identification of national Safe and Quality Use of Medicines activities
to be co-ordinated by the DHBNZ SQM
2. Prioritisation of these national Safe and Quality Use of Medicines
activities identified in the strategy document to be co-ordinated by
DHBNZ SQM
3. Promotion of a safety culture within the health sector and wider
community
4. Encouragement and support for more widespread involvement of all
DHB’s in safety and quality use of medicines initiatives
5. Identification of quality use of medicines initiatives at a local level so
that these can be evaluated and shared nationally
6. Maximisation of outcomes, minimisation of risks and improvement in
safety associated with medication use
A co-ordinated approach to the safe and quality use of medicines in New
Zealand is expected to take a number of years to become established.
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Policy
directives or
strategies to
date
(continued)
In their 2005 publication Safe and Quality Use of Medicines National
Strategy, the SUM Group identified 8 objectives.
1. To promote a culture of safety within the health sector and wider
community that supports leadership and coordination of quality and safe
use of medicine’s initiatives within all parts of the health sector
2. To encourage and support more widespread involvement of all DHBs’
in “Safe and Quality Use of Medicines” initiatives through the
establishment and support of active networks, dissemination of
information and ideas, and shared learning and review
3. To maximise outcomes, minimise risks and improve safety associated
with medication use by establishing, reviewing and improving practice
standards for all aspects of prescribing, dispensing and administration
4. To identify high risk medicines and high risk situations, including
those disease states targeted for special input in primary care eg
cardiovascular disease, diabetes and asthma. To identify options and
advocate for and implement solutions to minimise these risks
5. To improve the effectiveness and consistency of infrastructure such as
systems, processes, technology, information systems used by DHBs’ in
association with medication use
6. To improve health outcomes for patients who are treated in primary
care and DHB hospitals acknowledging that the interface between these
areas requires particular emphasis
7. To promote a culture of enquiry that fosters audit, monitoring and
evaluation, and research into the areas of “Safe and Quality Use of
Medicine”
8. To involve and engage consumers about the safe and appropriate use
of medicines and to increase consumer awareness in relation to the level
of medication errors in New Zealand
The Collaborative improvement programme combined with the
implementation of bar coding, as identified in this chapter will provide the
implementation plan for a number of these objectives.
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Policy
directives or
strategies to
date
(continued)
A variety of activities and initiatives are currently offered within DHBs
particularly within hospitals. Some hospitals undertake a significant amount
of drug utilisation review (DUR) work or guideline development and
implementation, while others have little resource to do so. Some hospitals
have their own formulary and process for maintaining that formulary. The
level of clinical pharmacy ward services provided and the degree to which
pharmacy services are involved in discharge procedures is also variable.
Drug information centres are in place in some areas and in some cases
provide smaller regional support services and assistance to the community
sector. Data collection systems, internal processes (such as established
medical committees etc) and staffing levels may be factors in the apparent
differences between hospitals in this regard.
Thus existing quality and safe use of medicine activities may include, but are
not limited to:
º
º
º
º
º
º
º
º
º
º
º
º
º
º
Drug utilisation review
Development of guidelines, formularies and pharmaceutical policies
Medication event (“incident”) reporting/management
Adverse drug reaction reporting/management
Medication disposal/management of discontinued medicines
Drug information services
Compliance aids
Quality assurance in relation to prescribing practice
Community/hospital transition management
Repeat prescribing in primary care
Consumer/practitioner education methods (e.g. peer review, feedback,
self-audit etc) and material (e.g. bulletins, Consumer Medicine
Information etc).
Quality assurance in relation to dispensing, distribution and
administration of medicines in hospitals and in the community.
Clinical pharmacy services/medication review services.
Critical appraisal of medical literature.
As one can see there are many activities that one could do, part of the
challenge is to use the very limited resources in an effective manner.
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Policy
directives or
strategies to
date
(continued)
A recent survey of DHBs which was undertaken to identify activity that
relates to the six priorities for quality has revealed that a number of DHBs are
working on various aspects of incident management and the reduction of
medication errors and harm.
Strategies that were identified through the survey include:
º Waikato DHB: A trial of the PYXIS system, review of the medication
chart, improved documentation of patient allergies and adverse drug
reactions, development and monitoring of medication storgage standards
document control of standing orders and development of prescribing
guidelines.
º Wairarapa DHB: The introduction of bedside dispensing and the
trialling of a new format medication chart.
º Counties Manakau DHB: Include strategies for improving the
management of high risk medications, anti-coagulant and antibiotic
improvements, Drug Utilisation Evaluation (DUE) of ciprofloxacin,
surgical prophylaxis, a "Nil by mouth not Nil by Medicines" for surgical
patients, allergy reporting and adherence to policy, electronic discharge
summary in AT&R, ‘One Chart' draft development medication review and
reconciliation.
º Northland DHB: Storage /identification of medications that are multi
strengths storage of medications for self administration and development
of a medication focus group
º Otago DHB: implemented electronic prescribing and the rollout of
electronic administration continues
º Bay of Plenty DHB: has implemented a programme to improve morphine
management.
º Auckland DHB: has had a medication safety plan in place since August
2004. The key strategies involve working on communication and
leadership for safety, the safety culture, medication incident notification
and management, high risk medication management, medicines
reconciliation supporting technology and community involvement in
medication safety. Further, Auckland DB is engaged in a community
medications reconciliation programme. An attempt will be made to
include this programme in the proposed collaborative process.
º Waitemata DHB: has implemented the PYXIS system across the whole
DHB. This DHB also has a data base that records every medication error
that is reported by pharmacists and provides feedback to clinicians on
these issues.
º Taranaki DHB: has also implemented the PYXIS ystem across the whole
DHB.
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Bar coding of
medicines
A further significant strategy that has commenced in the NZ Health and
disability sector is the development of a case for the implementation of bar
codes for unit doses of medications. It has been shown in health systems in
other countries that the introduction of bar code systems has significantly
reduced the number of medication errors and consequently prevented large
numbers of patient deaths and injury.
In industries outside of health, bar code technology has been widely adopted
because of its ease of use and high degree of reliability. In the context of
pharmacy dispensing, if all medications in the pharmacy had a bar code
scanned to ensure that the correct medication in its correct dose and
formulation is being dispensed, dispensing errors may be substantially
reduced. On the basis of these theoretical benefits for patient safety, the US
Food and Drug Administration mandated bar codes for all medication use in
hospitals in the US by April 2006.
It is suggested that bar coding should be introduced in the in the NZ health
and disability sector because of the benefits that bar coding has to patients,
specifically Bar coding can reduce the length of stay of patients in hospital,
and significantly reduce mortality and morbidity. This can also result in
savings to DHBs, through efficiencies gained in the supply-chain.12
A process of consultation and business case development for the
implementation of bar codes has already commenced and will continue on its
current course.
The further improvement strategies identified in this report will work had in
glove with the implementation of bar coding to ensure the effectiveness of the
system when it is implemented.
12
Ministry of Health (2006) Health Report: Bar Coding Medicines: A patient safety and DHB cost effectiveness
proposal.
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Work place
change to
accompany bar
coding
As identified in the previous section of this report, technological solutions to
patient safety problems are very important. Human factors research has
shown in recent years that better systems design and the implementation of
good technology can provide engineered barriers and forcing functions in
systems that reduce a persons capacity to make mistakes. If developed
correctly, the bar coding system has the capacity to do this.
However, it must be recognised that just the implementation of a
technological solution will not necessarily result in improvement. If the
purpose of the system is not recognised and the culture of the organisation is
not conducive to the use of the system, humans will find ways to over ride the
benefits. It has for example been noted in the VA health system in the US that
well intentioned nurses were able to establish “work-arounds” so that they
didn’t disturb patients whilst they were sleeping. It is essential to develop the
safety culture in an organisation, and the work practices that are going to be
supported by the new technology before the technology is implemented.
The IHI Collaborative improvement process proposed in this report will do
just that. It will be implemented whilst the bar coding system development is
taking place and in fact will, in part, inform the functional specification of the
bar code system.
Common
medication
chart
A national medication chart project is well underway in New Zealand and is
being sponsored by the Safe and Quality Use of Medicines Group. The
project started as a Waitemata DHB initiative to review and update their
medication chart. The project evolved into the design of one medication chart
after the initial redesign was presented ast the national hospital Pharmacists
Conference in 2003. Several overseas and NZ medication charts were
collected and reviewed and the best features were incorporated into a design
that was sent out for consultation twice in 2004
The chart is now ready for implementation across the country. This
implementation will form part of the Collaborative proposed in this report.
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Review of international action
International
strategies
A search of the literature and the internet has revealed that many, many
countries have over recent years placed an emphasis on the improved
management of medications. A variety of processes and methods has been
used to achieve change and improvement. It appears that a common approach
has been to undertake a Breakthrough Series or Collaborative as developed by
the Institute for Healthcare Improvement (IHI) in the United States.
A number of collaboratives have been conducted in the United States, some
by the IHI and others by health care provider organisations. The objectives or
goals for these various collaboratives have varied and included improving
º oral medication administration in the home setting
º medicines reconciliation between the community and the inpatient
setting and within the inpatient setting at points of transfer of care
º reducing harm (generally)
º improving the management of high risk drugs
º drug labelling
º patient self administration of medicines
º correct patient identification for drug administration
º the legibility of medication charts
Other strategies adopted internationally have included
 the implementation of bar coding systems
 model of a combination of teamwork and information sharing, the
participating VA facilities reported an improvement in medication
management
 the use of interactive voice response systems (IVR)
 the implementation of automated dispensing systems that help ensure that
medications are secure, organized, tracked and ready for use. Such
systems help health care professionals to reduce or eliminate labourintensive tasks by automating the management of medications. (PYXIS is
one brand of such machines.)
 pharmacist participation on post-admission ward rounds.
One national medication chart has been introduced in many countries for the
purposes of standardisation of prescribing, and administering drugs. The NHS
in the UK standardised their charts in 1960, introducing two format designs.
More recently Australia and Wales have introduced national medication
charts. Studies in Queensland suggest the implementation of their standard
medication chart has reduced the relative risk of errors by 25%.13 It is
therefore recommended that one chart be introduced in NZ. If this is not
possible for some reason, the recommendation would be to introduce one
chart across a whole region or district.
13
National Inpatient Medication Chart www.health.wa.gov.au/nimc/faqs/index.cfm
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The Australian
National
Medication
Safety
Breakthrough
Collaborative
Probably one of the most ambitious improvement strategies that was
undertaken by the Australian Council for Safety and Quality in Health Care
was the National Medication Safety Breakthrough Collaborative (NMSBC).
It began in September 2003 and the final conference presentation session was
held in May 2005. . The Collaborative aimed to achieve a national
improvement in medication safety by
º reducing harm associated with medication use by 50% among clients of
participating healthcare teams
º developing a national network and system to sustain and transfer
improvements in medication safety to other health services following the
completion of the collaborative.
One hundred teams from all States and Territories of Australia participated
and these teams were divided into two waves. Wave 1 teams focussed on
medication processes and high risk medications in the acute care setting .
Wave 2 teams worked to improve the community issues for medication
practices. The teams took a multidisciplinary approach to the project and team
membership was drawn from nursing, medicine, quality and pharmacy,
included an executive sponsor, a community representative and a consumer.14
As the lessons and improvements from this Collaborative have been
published, they are able to form the basis upon which a similar Collaborative
(but of course far better!) can be conducted in the NZ health and disability
sector.
14
Australian Council for Safety and Quality In Health Care (2005) Medication Safety The Breakthrough
Collaborative Project Chronicle
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World Patient
Safety Alliance
To address the issue of patient safety, an “Action on Patient Safety” (High 5s)
initiative—supported by the Commonwealth Fund and sponsored by the
World Health Organization’s (WHO) World Alliance for Patient Safety—is
proposed. This initiative seeks to leverage the implementation of five
standardised patient safety solutions that would have broad impacts in
preventing avoidable catastrophic adverse events (death or serious injury) in
hospitals.
The initiative will build on the established partnership and collaboration built
by the Commonwealth Fund with Australia, Canada, New Zealand, the
United Kingdom and the United States and the more recent expansion of its
international program to include Germany and the Netherlands.
The objective of the initiative is to achieve significant, sustained and
measurable reduction in the occurrence of 5 patient safety problems over 5
years in at least 7 countries and build an international, collaborative learning
network that fosters the sharing of knowledge and experience in
implementing innovative, standardized, safety operating protocols
The following 5 solution areas have been selected as the focus of the High 5s
initiative. These are derived from the international priorities for solutions
development which form the basis for the work of the Collaborating Centre:
1. Prevention of patient care hand-over errors
2. Prevention of wrong site / wrong procedure / wrong person
surgical errors
3. Prevention of continuity of medication errors
4. Prevention of high concentration drug errors
5. Promotion of effective hand hygiene practices
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The recommended programme scope
Introduction
This section of the report provides the details of the intended approach to
improving medication management in the health and disability sector. The
proposed programme will bring together the several bodies of work that are
being undertaken now and will provide an implementation plan for many
other proposed but as yet not implemented initiatives.
This proposal combines :
 the medicines bar coding project
 the implementation of a common medication chart that the QSM
Group with DHB NZ are sponsoring
 the work that is proposed with the World Patient Safety Alliance and
 the current efforts of the DHBs around improving medication
management.
Programme
objectives
The primary objectives of a national medication management programme
are:
1. Reduced harm caused to patients
2. Improved medication safety and effectiveness (reduced medication
errors improved benefit)
3. Implementation of a technical solution that will assist clinicians to
provide medications to patients/consumers more safely.
The secondary objectives are to improve medication safety by :
 implementing a common medication chart in each of the health and
disability regions
 introducing effective medication reconciliation to all health and
disability services
 effectively managing high risk drugs
 introducing better work practices to prepare the workplace for the
effective implementation of the medications bar coding system
 developing all the components of the bar coding system.
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There are two main components of this programme that need to be
developed and implemented in parallel over approximately eighteen
months to two years. By the end of this period the two components will
come together to form an integrated medication management system for
New Zealand.
COMPONENT 1
COMPONENT 2
A Breakthrough Series Collaborative
for:
Common medication chart
Medicines reconciliation
High risk drugs management
Work practice change
Development of bar coding
system
Implementation of the bar coding
system
18 – 24 months
Scope summary
An integrated consistent
approach to medication
management across all
health and disability
services
Ongoing
Ongoing national:
Monitoring, support, education
and training for providers
Policy development for
improving medication
management
System maintenance
Continued on next page
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Implementation Plan
Collaborative
Method
The method to be used to achieve nation improvement in medication
management will be a modified Breakthrough Collaborative Process. The
Breakthrough process was designed by the Institute of HealthCare
Improvement in the US and has been use across the work to bring about
sustainable improvement over multiple sites over a relatively short period of
time.
The Breakthrough Series is designed to help organisations close that gap by
creating a structure in which interested organisations can easily learn from
each other and from recognized experts in topic areas where they want to
make improvements.
A Breakthrough Series Collaborative is a short-term (6 - to 15-month)
learning system that brings together a large number of teams from hospitals or
other health and disability services to seek improvement in a focused topic
area.
Collaboratives range in size from 12 to 160 teams. This Collaborative would
have 21 teams; one from each of the DHBs. Each team typically sends five of
its members to attend Learning Sessions (three face-to-face meetings over the
course of the Collaborative identified as LS on diagram 3.1), with additional
members working on improvements in the local organisation. Some
collaborative processes have found that an orientation session for teams
before the Learning Sessions start is of great value. Teams in such
Collaboratives have achieved dramatic results, including reducing waiting
times by 50 percent, reducing worker absenteeism by 25 percent, reducing
ICU costs by 25 percent, and reducing hospitalisations for patients with
congestive heart failure by 50 percent. In addition, IHI has trained over 650
people in the Breakthrough Series methodology, thus spawning hundreds of
Collaborative initiatives throughout the health care world.15 A final, followup Conference to better ensure sustainability of the improvement results
achieved, is held approximately 7 months after the completion of the last
learning session.
Further information about how the Collaborative process works can be found
at Appendix 1 to this report.
15
www.ihi.com
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Timeframes
The Collaborative Process 15
Diagram 3.1
Sept ‘07
Sept – Nov ‘07
May also have
Orientation Session for
teams during this time
Oct ‘07
June‘07
Bar Coding
Development
Method
Dec ‘07
Feb‘08
May ‘08
Dec ‘08
The method for development of the Bar Coding system is not identified in
this report. A separate process is being developed by the Ministry of Health.
This process will be closely co-ordinated with the Collaborative process to
ensure that the workplace changes that are required for the successful
implementation of the bar coding system are achieved through the
Collaborative in readiness for the implementation of bar coding.
Consumer
Consumers need to be involved in this programme, from its commencement,
involvement in
in the following ways.
this programme
 Consumers will provide expertise on improvement strategies and will


Exclusions
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form part of faculty and expert group
Each participating team from the DHBs will be required to have a
consumer member
Consumers will be invited to participate in focus groups to inform the
diagnostic process in each of the DHBs
Private health care organisations
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Action required
at levels of
organisation
The Ministry will be responsible for
 Development and issue of national policy
 Development of a nationally coordinated implementation plan
 Oversight of implementation including project management for the
Collaborative process
 Development and implementation of the bar coding system
Safe and Quality Use of Medicines Group could perhaps sponsor the
programme and provide substantial input to the Expert Group
The DHBs will be responsible for
 DHB level policy development that reflects national policy
 Providing the right people to participate in the Collaborative
 Providing local project management resource
 Providing and overtly displaying leadership, guidance and support for
the programme.
The Collaborative teams from the health and disability services will be
responsible for:16
 being dissatisfied with the status quo and being ready for ambitious
change
 having a commitment to a rigorous diagnosis of the current system
 seeking improvements that will deliver the greatest benefits to patient
safety through medication management
 agreeing to make measurable changes within six months to improve
medication management
 seeking to develop service improvement skills
 investigating all relevant processes, patterns and structures that impact
on medication management
 applying creativity and eagerness to willingness to test improvements
 having a willingness to address cultural issues at an executive level.
16
Adapted from the Victorian Patient Flow Collaborative requirements.
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