Standard 4: Medication Safety

Provision of a medicines list

Action 4.12

The health service organisation has processes to:

a. Generate a current medicines list and the reasons for any changes

b. Distribute the current medicines list to receiving clinicians at transitions of care

c. Provide patients on discharge with a current medicines list and the reasons for any changes

Intent

Medicine-related problems and risk of patient harm are minimised by maintaining a current medicines list with reasons for any changes, and providing it in a suitable format for clinicians at transfer of care and patients on discharge.

Reflective questions

What processes are used by clinicians to document and maintain a current medicines list during a patient’s episode of care?

How do clinicians generate a current medicines list, including reasons for any changes, to use at clinical handover and provide on discharge?

Key tasks

  • Implement processes that support clinicians to generate and maintain current medicines lists throughout an episode of care
  • Incorporate the use of medicines lists into clinical handover procedures
  • Implement a process to provide current medicines lists and the reasons for any changes to patients on discharge.

Strategies for improvement

Hospitals

Implement processes to generate and maintain current medicines lists

Provide access to the system that supports medication management (including documenting medicines lists) in all clinical areas within the health service organisation to create ‘one source of truth’. This reduces the risk of miscommunication and errors as the patient moves through the health service organisation. It also improves the quality of medicine-related information that accompanies the patient and ensures that it is available for clinical decision-making.

The system may be paper based (for example, the medicines list section in a manually prepared discharge summary) or electronic; however, paper-based systems provide greater opportunity for error and can be resource intensive.

Introduce work practices and service delivery models that link the production of medicines lists with prescribing processes and medication supply systems, to improve communication when transferring care.

Review organisational policies, procedures and guidelines for medication management and medication reconciliation (linked to Action 4.6) to include generating and maintaining a current medicines list on admission, and updating it when necessary during the episode of care and when transferring care. Consider:

  • How and where the list will be accessed and maintained
  • The minimum information to be documented (refer to the definition in the Glossary)
  • The roles, responsibilities and accountabilities of clinicians
  • Reconciling discrepancies and communicating updates or changes to the medicines list
  • Assessing and managing the risks associated with maintaining and generating medicines lists
  • Auditing the documentation on admission, and provision on discharge, of medicines lists using relevant indicators.

Review work practices for documenting a patient’s current medicines when the patient is admitted to the health service organisation, and for maintaining a record in a standard format and in a consistent place, such as:

  • On the PBS HMC
  • On the MMP or equivalent
  • On the NIMC
  • In the electronic medication management system
  • In the pharmacy’s dispensing system
  • In an alternative standalone electronic module, such as those developed and used by some states or territories (for example, Queensland Health’s Enterprise-wide Liaison Medication System).

A standard procedure for transferring current medicines lists that contain at least the minimum requirements could include an electronic transfer summary, a copy of the current NIMC and MMP (or equivalent record), or an event summary in the patient’s digital healthcare record.

Incorporate medicines lists into clinical handover procedures

Continuity of medication management includes generating, maintaining and communicating a current list of medicines and the reasons for changes at clinical handover (including shift changes and movement between clinical areas/wards; see Action 6.7 and 6.8).

It is critical to communicate the patient’s current medicines list, along with any medicine-related problems or adverse drug events that have occurred during a shift or episode of care (see Action 4.6). A medicine-related problem may include a patient refusing or missing a dose of medicine, or withholding a medicine.

Ensure that clinical handover training includes the principles of continuity of medication management, and the construction of a current medicines list and the reasons for changes, tailored for communicating to the intended audience (for example, clinicians or patients).

Ensure that policies, procedures and guidelines for clinical handover include communicating issues relating to a patient’s medication management during their episode of care, and the roles, responsibilities and accountabilities of clinicians.

Establish a set of key elements relating to medication management in clinical handover, such as identifying high-risk patients, high-risk medicines, and the priorities for maintaining treatment and achieving patient treatment goals (see Action 4.3).

Rather than developing a separate handover tool, and in the absence of integrated electronic medication management, health service organisations may use the MMP (or equivalent form) along with the current NIMC to support the transfer of critical medicines information at clinical handover or when the patient is transferred, reinforcing the concept of ‘one source of truth’.

Monitor and evaluate the process for communicating critical medicines information during clinical handover. Consider:

  • Medicine-related incidents relating to inadequate information transfer
  • Content and the quality of content
  • Feedback and evaluation of information transfer tools.

Provide current medicines lists and reasons for any changes to receiving clinicians at transfer or on discharge

To improve communication about medicines and continuity of medication management, minimise delays, and reduce the risk of medicine-related problems after transfer or discharge:

  • Provide a current reconciled medicines list, in a standard format (discharge summary, either paper or electronic), that includes the essential elements of the medicines list and an explanation of any changes made to therapy during the episode of care
  • Prepare the medicines list in partnership with the patient
  • Provide clear instructions for ongoing care and follow-up requirements, if relevant
  • Ensure consistency between medicines lists that are
    • provided to the patient
    • in the discharge summary
    • in the patient healthcare record
  • Resolve any discrepancies with prescriptions written on discharge before finalising the discharge medicines list
  • If possible, transfer the medicines list electronically along with other discharge information to the patient’s general practitioner and community pharmacy, and to the patient’s digital healthcare record
  • Incorporate the process of obtaining informed consent for transfer of medicines information to general practitioners and community pharmacists into standard work practices.

When transferring patients to other organisations, implement a standard procedure for transferring an updated medicines list and reasons for any changes. This could be an electronic transfer summary, or a copy of the current NIMC and MMP (or equivalent record).

Tailor the discharge format of the medicines list to the needs of the recipient (for example, the general practitioner, community pharmacist or other clinicians, as well as any organisation that the patient is being transferred to).

Extra documentation may be provided in specific situations, such as transfer to residential care facilities. This should be outlined in the relevant policies, procedures and guidelines.

Provide current medicines lists and reasons for any changes to patients on discharge

Provide information for patients and carers that explains the medicines list and its purpose as leaflets, brochures, posters or the health service organisation’s patient information handbook (see Action 4.11 for other medicine-related information that would be expected to be provided on discharge). Tailor the discharge format of the medicines list to the needs of the patient.

Review organisational discharge policies, procedures and guidelines to include the requirement for a current medicines list to enable continuity of medication management.

Ensure that policies, procedures and guidelines outline:

  • Who is responsible for preparing the medicines list and reconciling the content and its accuracy (for example, alignment with the discharge summary and medicines dispensed on discharge)
  • The patients who should receive medicines lists; consider determining a priority for those patients most at risk of medicine-related problems, using existing or locally developed risk assessment tools that also consider health literacy and cognitive ability
  • How patients and carers are involved in the process, and how their individual needs and risks are considered in the preparation of medicines lists (for example, consider a patient’s usual medicine-taking routine or their ability to manage, including cognitive or physical impairment, or language barriers)
  • The format of the list, which should be tailored to the patient’s needs
  • Incorporation of the medicines list into counselling of patients and carers (see Action 4.11).

Ensure that multidisciplinary discharge planning and work practices:

  • Enable gaining of consent to supply a copy of the medicines list, reasons for changes, and any other essential medicine-related information to the patient’s nominated community care providers, such as their general practitioner, community pharmacy, residential care provider or other clinician
  • Include the practice of reconciling medicines
  • Encourage preparation of medicines lists in partnership with patients
  • Enable timely generation to ensure that patients and carers receive the updated medicines list on discharge
  • Include discussion between the patient and the responsible clinician (for example, discharge counselling provided by a pharmacist) about the purpose and use of the medicines list, the need to keep it up to date, and the need to take it with them each time they visit a health service organisation, including whenever they go to hospital
  • Make provision for an event summary to be loaded into the patient’s digital healthcare record.
Day Procedure Services

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

Implement a policy whereby patients and carers are informed about any medicines they are required to take post-discharge and any changes made to their regular medicines.

When changes have been made to a patient’s current therapy, inform the patient about the changes and update the medicines list to reflect the changes, where applicable.

Refer to the hospitals tab for more detailed implementation strategies for this action.

Examples of evidence

Select only examples currently in use:

  • Policy documents that outline the generation, distribution and provision of a medicines list (with reasons for any changes) to patients and clinicians, including at transitions of care and on discharge
  • Audit results of documenting medicines lists on admission
  • Audit results of providing a medicines list to patients on discharge
  • Orientation or training documents about generating and updating medicines lists
  • Documented process to gain consent before sharing a patient’s medicines list on discharge
  • Examples where medicines lists have been tailored to the specific needs of recipients (patient, general practitioner, community pharmacist).
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established processes for generating and distributing medicines lists.

Small hospitals that are not part of a local health network or private hospital group should:

  • Implement processes that support clinicians to generate and maintain current medicines lists throughout an episode of care
  • Incorporate the use of medicines lists into clinical handover procedures
  • Implement a process to provide current medicines lists and the reasons for any changes to patients on discharge.

Work practices and service delivery models that link the production of medicines lists with prescribing processes and medication supply systems can improve communication when transferring care.

Review work practices for documenting a patient’s current medicines when the patient is admitted to the health service organisation, and for maintaining a record in a standard format and in a consistent place.

A standard procedure for transferring current medicines lists that contain at least the minimum requirements could include an electronic transfer summary, a copy of the current NIMC and MMP (or equivalent record), or an event summary in the patient’s digital healthcare record.

During clinical handover, it is critical to communicate the patient’s current medicines list, along with any medicine-related problems or adverse drug events that have occurred during a shift or episode of care. A medicine-related problem may include a patient refusing or missing a dose of medicine, or withholding a medicine.

Rather than developing a separate handover tool, and in the absence of integrated electronic medication management, health service organisations may use the MMP (or equivalent form) along with the current NIMC to support the transfer of critical medicines information at clinical handover or when the patient is transferred, reinforcing the concept of ‘one source of truth’.

Provide current medicines lists and reasons for any changes to receiving clinicians at transfer or on discharge

To improve communication about medicines and continuity of medication management, minimise delays, and reduce the risk of medicine-related problems after transfer or discharge:

  • Provide a current reconciled medicines list, in a standard format (discharge summary, either paper or electronic), that includes the essential elements of the medicines list and an explanation of any changes made to therapy during the episode of care
  • Prepare the medicines list in partnership with the patient
  • Provide clear instructions for ongoing care and follow-up requirements, if relevant
  • Ensure consistency between medicines lists that are
    • provided to the patient
    • in the discharge summary
    • in the patient’s healthcare record
  • Resolve any discrepancies with prescriptions written on discharge before finalising the discharge medicines list
  • If possible, transfer the medicines list electronically along with other discharge information to the patient’s general practitioner and community pharmacy, and to My Health Record
  • Incorporate the process of obtaining informed consent for transfer of medicines information to general practitioners and community pharmacists into standard work practices.

Tailor the discharge format of the medicines list to the needs of the recipient (for example, the general practitioner, community pharmacist or other clinicians, as well as any organisation that the patient is being transferred to).

Other documentation may be provided in specific situations such as transfer to aged care homes. This should be outlined in the relevant policies, procedures and guidelines.

Provide current medicines lists and reasons for any changes to patients on discharge

Provide information for patients and carers that explains the medicines list and its purpose as leaflets, brochures, posters or the health service organisation’s patient information handbook. (see Action 4.11 for further medicine-related information that would be expected to be provided on discharge). Tailor the discharge format of the medicines list to the needs of the patient and incorporate the medicines list into the counselling of patients and carers (see Action 4.11).

Last updated 4th July, 2018 at 07:20pm
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