Improving patient safety

through standardisation

WAMSG Symposium 2014

October 17, 2014

Helen Stark

Senior Project Officer

Standardisation in medication management

National Inpatient Medication Chart

Observation and response charts

National terminology, abbreviations

Tall Man Lettering

Medication Management Plan

National Subcut. Insulin Form

Residential Aged Care Medication

Chart (NRMC)

PBS Supply and Medication Chart

Aim: To reduce risk of medication errors and harm through

standardising processes in the medication management pathway

Improving patient safety

Recognition errors occur because of systems

breakdown

Reduce errors by redesigning systems

Human factors area of study

“the study of the interrelationship between humans,

the tools and equipment they use in the workplace

and the environment in which they work”1

1. Kohn LT et al. To err is human – building a safer health system. Washington DC, Committee on Quality of Health Care in

America, Institute of Medicine, National Academy Press, 1999.

Heuristic analysis & human factors

testing in medication chart development

Heuristic analysis - method of systematically reviewing & identifying design problems

Charts are evaluated by independent, trained evaluators against pre-determined design categories

Design & usability problems are identified - layout, recording of information, language and labelling, cognitive and memory load, use of fonts, use of colour, etc

Based on findings, recommendations for revised chart design are made

Example - Recording of vital signs as

numerical data *

Raters considered information

displayed numerically rather than

plotted as a graph to be problematic

The majority of charts did not display

all vital signs as graphs. This was

argued to make it difficult to notice

deterioration

* with permission, Associate Professor Mark Horswill

School of Psychology, The University of Queensland

Recording of vital signs as graphs*

This chart uses graphs to show the same data as in the previous slide

Deterioration is easier to see

* with permission, Associate Professor Mark Horswill School of Psychology, The University of Queensland

Overlapping plots on graphs

Many charts had

graphs where 2 or

more vital sign plots

could be confused

Here’s an example

of how multiple plots

on same graph

could be confusing

Recording of vital signs as graphs

The same

3 plots

were

considered

clearer

when

separated

Medication Chart Development

Identify processes suitable for national standardisation

Medication Reference Group, Expert Advisory Groups

Local and international initiatives

Developed in response to harm from medication error

Establish reference groups

Advise on development and implementation of intervention

Oversight of pilot studies

Recommendations for national roll out

Medication Chart Development

Implementation

Support, resources

Communication

Incorporation into training

Evaluation

Maintenance

Oversight by Expert Advisory Groups

Issues register

Quality improvement program

Version control

National Inpatient Medication Chart (NIMC)

• Piloted in 2005

• 31 sites

• Prescribing errors by 1/3

• Improved documentation

• Introduced

• Public Hospitals 2006-2007

• Private Hospitals 2007-2011

• Design incorporated:

• Safety features

• Forcing functions/prompts

• A single chart

• Human factors engineering

• Specialist versions:

• Long-stay version (2006)

– 28 days

• Paediatric versions (2009)

– Acute

– Long stay

• Electronic four A4 page version (2009)

– Rural hospitals

– GP generated

Specialist versions

User guide

User advice 4 A4 Page NIMC

Local management guidelines

Paed NIMC

education resources

Online learning tool (NPS)

Familiarise learners with NIMC

Raise awareness of safe prescribing, administering practices

Reduce medication errors

Support materials

Annual National Audit

Web based reporting tool

Comparative reports

Individual hospitals

State

National

Quality Improvement

Local management, quality assurance and

issues register

There are standard processes for:

managing the NIMC locally (state/territory)

elevating issues that cannot be managed locally

recording issues considered nationally including outcomes

NIMC Local Management Guidelines

There is a process for considering quality adjustments to the NIMC

that will improve medication safety.

The NIMC Local Management Guidelines provide information on

managing the NIMC locally, including possible changes at the local

level

Health Service Medication Expert Advisory

Group (HSMEAG)

HSMEAG advises Commission on the NIMC and related

issues

The group consists of representatives from public and private

hospitals, jurisdictional medication representatives and

clinical and professional groups

Requests for changes to the NIMC : evidence-based and are

considered at the local (state or territory) level first

Requests not resolved at local level are considered by

HSMEAG and a register maintained of requests and

outcomes

Has patient safety improved?

Has patient safety improved?

•

Has patient safety improved?

NIMC online learning course: 13,639 completions between

1 July 2013 and 31 March 2014

Medical 14%

Nursing 39%

Feedback from 495 learners

96% reported knowledge in completing or reviewing NIMC accurately increased

94% reported confidence in using NIMC correctly had increased

“New staff arrive on the ward floor familiar with the medication chart”

1. NPS Evaluation report No 14, 2010-11

NIMC on line training course

National Subcutaneous Insulin Form

Background

Calls for standardised national insulin chart since 2007 to accompany the National Inpatient Medication Chart (NIMC)

Insulin accounts for around 15% of the highest risk incidents (actual and potential) experienced in acute care1

Insulin recognised nationally & internationally as a high risk medicine

2012: heuristic analysis of large number of insulin charts and decides to conduct national pilot using modified version of the QLD Health subcutaneous insulin form

1. Kerr M. Inpatient Care for People with Diabetes: The Economic Case for Change: National Health Service, 2011:52

Background

Create a record where all relevant aspects of a patient’s glyceamic management can be documented to facilitate decision-making

Pilot Subcutaneous insulin form has five functions:

record BGLs

record insulin orders (Rx)

record insulin administration

record outcomes of insulin administration

provide guidelines on how to manage diabetes

In-built safety features – BGL alerts, guidelines, pre-printed “units”

BGL Record & Monitoring

Insulin Administration

Insulin Orders

Guidelines for Managing

Hyperglycaemia Alerts

To assist inexperienced and non

specialist clinicians with

management of hyperglycaemia in

hospital inpatients. They provide

information related to:

assessment required when

called for a Hyperglycaemia Alert

initiation of basal and mealtime

insulin and adjustment of insulin

doses

suggested stat and supplemental

doses based on weight or previous

total daily dose

1

2

3

Management of Hypoglycaemia in

Diabetes - Adult

Background (cont.)

Commission formed expert advisory group to oversee pilot, consisting of technical experts, jurisdictional representatives & clinicians

EOI sent to hospitals in September 2012, pilot commences in early 2013, 8 hospitals in 3 states – VIC, WA and QLD

Methodology:

mplement pilot form over minimum of 6 months

Pilot concludes in early 2014

Evaluation:

Quantitative audit of medication charts

Qualitative research

Issues Register

Evaluation Results

Baseline: 302 patients, 464 insulin forms, 870 orders

Post-Audit: 270 patients, 538 insulin forms, 686 orders

Pilot subcutaneous insulin form improved:

Monitoring and documentation of BGLs

Clarity of insulin prescribing for routine, subcutaneous and

stat/phone insulin orders

Documentation of notification, and follow up management of hypo

and hyperglycaemia

Evaluation Results (cont.)

Fewer instances of hypogylaemia (<4mmol/L) and

hyperglycaemia (>20mmol/L)

An increase in BGLs in the upper range (12 - 20mmol/L)

Significant increase in missing routine insulin doses (1.7%

pre vs 3.5% post)

Average number of charts increased (1.54 pre vs 1.99 post)

106 routine insulin doses reported as missing in the post-audit

Evaluation Results (cont.)

Qualitative research - Advantages

BGLs and insulin orders on one form

Easily accessible guidelines, useful for junior doctors

Safety features including pre-printed units, BGL alerts

Improved prescription and administration clarity

Improved BGL management & response to change

Evaluation Results (cont.)

Qualitative research - Disadvantages

Daily insulin review & order - subsequent risk of omission

Design – orders not adjacent to admin. record causing confusion

Prescribers having to write the insulin name in two places (risk of

transcription error)

Chart layout “complex”, “busy”, “not intuitive”

However all report pilot chart “safer” than previous chart used

(NIMC, sliding scale forms)

One pilot hospital proposes modified design to align routine orders

with administration section, remove req. for daily orders

NIFPAG Recommendations

The National Insulin Form Pilot Advisory Group

recommends modifying the design of the form followed

by further pilot testing

However on “testing” the modified form, clinicians on

NIFPAG do not endorse proceeding directly to a 2nd

phase pilot instead majority recommend undertaking

further design and human factors testing

Current Status

University of Queensland will design a modified

subcutaneous insulin chart employing human factors

principles, using pilot chart as starting point

Conduct heuristic evaluations of the new chart(s) against

the National Pilot Chart

Modified chart - 2nd phase pilot in 2015

Expect final chart to be available late 2015

National Residential Medication Chart (NRMC)

Commission funded to develop a national standard medication

chart for use in RACFs as part of Fifth Community Pharmacy

Agreement

Piloted in NSW RACFs in 2013, evaluation report with Dept of

Health

NRMC aims to improve the safety of medication management

RACFs through standardised medication charting and

medication management practice

The NRMC permits supply and PBS claiming from the chart,

improving work flows for health professionals working in

residential aged care

National Residential Medication Chart

Current status of NRMC roll-out:

To use the chart requires change of legislation to permit PBS

claiming

WA,SA,ACT,TAS have amended their legislation and are ready

to use the NRMC once it goes live

Roll-out - questions about the chart should be directed to the

Department of Health or to Medicare (PBS)

PBS Hospital Medication Chart Project

Standardised national medication chart that will remove the

need for a separate paper prescription

AIM: To reduce the regulatory and administrative burden of

supplying PBS medicines in private and public hospitals

Builds on the outcomes from the NRMC project to allow for

paperless claiming of PBS eligible medicines

Phase one of the trial will involve the development of a paper-

based chart

Safety data collected from phase one will influence the design

of an electronic form in phase two of the project

PBS Hospital Medication Chart Project

The PBS Hospital Medication Chart will be piloted in private

hospitals from March 2015 with pilots in public hospitals to

commence in May

The paper-based chart will be available for use from mid-2016

nationally

Further information about the project can be found at:

http://www.safetyandquality.gov.au/our-work/medication-

safety/medication-chart/pbs-hospital-medication-chart/

Questions: Herbert Down at

Herbert.Down@safetyandquality.gov.au

Conclusion

Medication charts should be developed using human factors expertise

Standardising charts & processes in the medication management pathway:

Reduces risk of medication errors and harm

Facilitates education of health practitioners on safe medication practices using common resources and standard processes

Australian Commission on Safety and

Quality in Health Care

EHealth & Medication Safety Program

www.safetyandquality.gov.au

Email: mail@safetyandquality.gov.au

Acknowledgements

Contribution of :

Medication Services, Queensland Health to development of NIMC,

NIMC audit tool and national MMP & Subcutaneous Insulin Form

NSW TAG Safer Medicines Group to Recommendations for

Terminology, Abbreviations and Symbols used in the prescribing and

administration of medicines

Daniel Lalor to development and evaluation of Tall Man Lettering List

Health Services Expert Medication Advisory Group

Medication Continuity Expert Advisory Group

National Insulin Form Pilot Advisory Group

Hospitals participating in Subcutaneous Insulin Form Pilot