Standard 4: Medication Safety

Information for patients

Action 4.11

The health service organisation has processes to support clinicians to provide patients with information about their individual medicines needs and risks

Intent

Clinicians are supported to provide information to their patients about medicines options, benefits and risks.

Reflective questions

How do clinicians inform patients about options for their care, including use of medicines?

What information do clinicians provide to patients about the benefits and risks of medicine-related treatment options?

How do clinicians gain access to medicine-related information for patients?

Key tasks

  • Provide patients and carers with enough information about treatment options for them to make informed choices about their medicines, and to adhere to medicine-related treatment plans.

  • Support clinicians to provide medicine-related information when treatment options are discussed and when treatment decisions have been made.

Strategies for improvement

Hospitals

Actions 2.3–2.10 and Action 4.3 include requirements for organisation-wide processes for involving patients in their own care, shared decision making, informed consent and effective communication.

Refer to the strategies outlined for each of these actions when implementing Action 4.11.

Provide patients and carers with enough information

Providing medicine-related information is a multidisciplinary responsibility.

Provide medicine-related information in a form that can be used and understood by patients, and is sensitive to individual patients’ needs (for example, culturally appropriate). This includes providing a package to patients and carers on discharge that contains relevant medicine-related information (Action 4.12). Discuss the benefits and associated risks of any medicines, and use patient-specific written information (such as CMI) to help inform the patient about the medicine.

Include a section on medicines in patient information brochures about general health service organisation care and services, and in patient charter documents. This will help to inform patients that medicine-related treatment options will be discussed and information will be provided about medicines prescribed.

Refer patients and carers to education programs that include medicine-related information, such as cardiac rehabilitation programs, or chemotherapy education sessions for oncology or haematology patients and carers.

Review policies, procedures and guidelines

Ensure that organisational policies, procedures and guidelines include the requirement to:

  • Provide medicines information to patients and carers as part of the clinical consultation, using written information, if relevant, to help inform the patient about any new medicine
  • Document in the healthcare record that patients and carers have been informed about the medicine; documentation may occur as a component of the consent process, within the patient’s healthcare record (hard copy or digital), on the NIMC or on the MMP (or equivalent).

Review policies governing patient consent (Action 2.4) to include specific situations that require informed consent for treatment with a medicine (for example, Special Access Scheme medicines, off-label use of medicines).

Ensure that medicine-related information is available to clinicians

Ensure that clinicians have access to relevant, up-to-date medicine-related information (including reference materials and information tailored for patients) that is evidence based, at all stages of the medication management pathway (Action 4.13). This includes:

  • When clinicians discuss associated risks of any medicines, as well as treatment options, with patients (for example, before making a decision to prescribe or deprescribe)
  • When clinicians are counselling patients on the use of their prescribed medicines (for example, on discharge)
  • When medicines are being dispensed (for example, provide patients with CMI)
  • When medicines are being administered (for example, to educate patients on self-administration techniques, such as for inhalers or subcutaneous injections).

Use medicine-related information that has been tailored for patients, which has either been developed locally or sourced from reliable sites. Medicine-related information and materials that have been developed locally to meet a specific need must be endorsed by the organisation’s medication safety governance group.

Patient-specific medicine-related information can be accessed from:

Guidance for producing locally developed information includes:

Promote the availability and use of consumer-specific medicine-related information, tools and resources to clinicians using communication strategies such as newsletters, presentations, in-service education sessions and awareness campaigns.

Evaluate medicines information

Evaluate the content and usefulness of locally developed consumer-specific resources by obtaining feedback from consumers and clinicians.

Audit healthcare records to determine whether provision of medicine-related information has been documented, and provide feedback to clinicians. This evaluation could target specific medicines or at-risk patient groups. Resources for guidance include:

Day Procedure Services

Actions 2.3–2.10 and Action 4.3 include requirements for organisation-wide processes for involving patients in their own care, shared decision making, informed consent and effective communication.

Refer to the strategies outlined for each of these actions when implementing Action 4.11.

This action may not be applicable for day procedure services that provide evidence that they are not changing or altering patients’ medicines during an episode of care.

When medicines, such as prepacked medicines, are supplied by the service, patients should be counselled on how to take the medicines. Written information, such as CMI, should be provided.

When the patient is provided with a prescription to be dispensed in a community pharmacy, CMI should be provided by the dispensing pharmacist.

Provide patients and carers with enough information

Provide medicine-related information in a form that can be used and understood by patients, and is sensitive to individual patients’ needs (for example, culturally appropriate). This includes providing a package to patients and carers on discharge that contains relevant medicine-related information (Action 4.12). Discuss the benefits and associated risks of any medicines, and use patient-specific written information (such as CMI) to help inform the patient about the medicine.

Include a section on medicines in patient information brochures about general care and services provided by the health service organisation, and patient charter documents. This will inform patients that medicine-related treatment options will be discussed and information will be provided about medicines prescribed.

Refer patients and carers to education programs that include medicine-related information relevant to the day procedure service, such as cardiac rehabilitation programs, or chemotherapy education sessions for oncology or haematology patients and carers.

Review policies, procedures and guidelines

Ensure that organisational policies, procedures and guidelines include the requirement to:

  • Provide medicines information to patients and carers as part of any clinical consultation, using written information, if relevant, to help inform the patient about any new medicine
  • Document in the healthcare record that patients and carers have been informed about the medicine; documentation may occur as a component of the consent process, within the patient’s healthcare record (hard copy or digital), on the NIMC – day surgery or on the MMP (or equivalent).

Review policies governing patient consent (Action 2.4) to include specific situations that require informed consent for treatment with a medicine (for example, Special Access Scheme medicines, off-label use of medicines).

Ensure that medicine-related information is available to clinicians

Ensure that clinicians can access relevant, up-to-date, evidence-based medicine-related information (including reference materials and information tailored for patients) at all stages of the medication management pathway (Action 4.13). This includes:

  • When clinicians discuss associated risks of any medicines, as well as treatment options, with patients (for example, before making a decision to prescribe or deprescribe)
  • When clinicians are counselling patients on the use of their prescribed medicines (for example, on discharge)
  • When medicines are being dispensed (for example, provide patients with CMI)
  • When medicines are being administered (for example, to educate patients on self-administration techniques, such as for inhalers or subcutaneous injections).

Use medicine-related information that has been tailored for patients, which has either been developed locally or sourced from reliable sites. Medicine-related information and materials that have been developed locally to meet a specific need must be endorsed by the organisation’s medication safety governance group.

Patient-specific medicine-related information can be found at:

Guidance for producing locally developed information includes:

Promote the availability and use of consumer-specific medicine-related information, tools and resources to clinicians using communication strategies such as newsletters, presentations, in-service education sessions and awareness campaigns.

Evaluate medicine-related information

Evaluate the content and usefulness of locally developed consumer-specific resources by obtaining feedback from consumers and clinicians.

Audit healthcare records to determine whether provision of medicine-related information has been documented, and provide feedback to clinicians. This evaluation could target specific medicines or at-risk patient groups. Resources for guidance include:

Examples of evidence

Select only examples currently in use:

  • Policy documents that define the roles, responsibilities and accountabilities of the clinical workforce in informing patients and carers about their individual medicines needs and risks
  • Audit results of workforce compliance with policies, procedures, protocols and guidelines for informing patients and carers about their individual medicines needs and risks
  • Observation that information about medicines needs and risks is available for clinicians to use during discussions with patients and carers
  • Examples of resources that can be provided to support discussion about patients’ medicines needs and risks
  • Results from evaluation of the usefulness of locally produced medicine-related information, and patients’ understanding of their medicines needs and risks
  • Communication with the workforce that promotes the importance of discussing medicines needs and risks with patients.
MPS & Small Hospitals

Actions 2.3–2.10 and Action 4.3 include requirements for organisation-wide processes for involving patients in their own care, shared decision making, informed consent and effective communication.

Refer to the strategies outlined for each of these actions when implementing Action 4.11.

Provide patients and carers with enough information

Providing medicine-related information is a multidisciplinary responsibility.

MPSs and small hospitals should provide patients and carers with enough information about treatment options for them to make informed choices about their medicines, and to adhere to medicine-related treatment plans.

Provide medicine-related information in a form that can be used and understood by patients, and is sensitive to individual patients’ needs (for example, culturally appropriate). This includes providing a package to patients and carers on discharge that contains relevant medicine-related information (Action 4.12). Discuss the benefits and associated risks of any medicines, and use patient-specific written information (such as consumer medicine information, or CMI) to help inform the patient about the medicine.

Review policies, procedures and guidelines

Ensure that organisational policies, procedures and guidelines include the requirement to:

  • Provide medicines information to patients and carers as part of the clinical consultation, using written information, if relevant, to help inform the patient about any new medicine
  • Document in the healthcare record that patients and carers have been informed about the medicine; documentation may occur as a component of the consent process, within the patient’s healthcare record (hard copy or digital), on the NIMC or on the MMP (or equivalent).

Ensure that medicine-related information is available to clinicians

MPSs and small hospitals should support clinicians to provide relevant, evidence-based, up-to-date medicine-related information for when treatment options are discussed and when treatment decisions have been made. This information may be available from the Local Hospital Network, state or territory health department or nearby larger hospital.

In addition, patient-specific medicine-related information can be found at:

Audit healthcare records to determine whether provision of medicine-related information has been documented, and provide feedback to clinicians. This evaluation could target specific medicines or at-risk patient groups. Resources for guidance include:

Last updated 4th July, 2018 at 07:09pm
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