Aotearoa Patient Safety Day 2022

Te Whatu Ora Counties Manakau

Here is how Counties Manukau Te Whatu Ora celebrated Aotearoa Patient Safety Day on Thursday 17 November. 

Competitions 

• Teams and wards were asked for creative submissions to illustrate the theme ‘How can medicines without harm be achieved at transfer of care?’ 

• The Kidz First team made a video to show how they work collaboratively within the multidisciplinary team and with patients and whānau when discharging medically complex children. 
• The Palliative Care team developed resources to educate whānau about administering subcutaneous medicines and changing the syringe in the syringe driver at home. The resources include two videos that can be accessed easily by scanning a QR code. 

• Clinicians provided examples of situations in which they demonstrated any or all of the three Ps for a patient. 

• The urology nurse specialist in the Manukau Super Clinic made a fantastic video outlining how she educates her patients about medicine changes (with the help of interpreters where necessary), documents medicine changes on her clinic letters and keeps patients’ general practitioners in the loop. 

• Nurses and prescribers competed in a quiz that delivered important learning points for medicines at transfer of care specific to Counties Manukau. 

Educational activities 

• Staff held a stall with various activities to promote medication safety at transfer of care: 

• Green bag reconciliation activity: Staff were presented with a green bag and discharge summary for ‘Minnie Mouse’ and asked to have a look and discuss what they would talk to the patient about and whether they would have any questions about the medicines. Staff were expected to note that the green bag contained aspirin that had been ceased on discharge and insulin that was labelled as prescribed for another patient. Guidance was available if these issues were not identified. 
• Patient information activity: Staff were asked to show where to go to print information on iron (ferrous sulphate) on New Zealand Formulary/Health Navigator, specifically to answer the question ‘Do you need to worry about dark stools?’ 
• To take out (TTO) activity: A sample TTO form and bag from the pharmacy provided an opportunity to talk to staff about the TTO medicine process. 
• Medication counselling cards (eg, for warfarin, rivaroxaban, bone protection): Staff learned about using these cards to counsel patients on discharge. 
• After hours pharmacies: Staff were asked how to find out which pharmacies are open after hours. If they weren’t sure, they were shown how to use Health point to find this information. How to find a pharmacy. 

• Green bag process: Clinical pharmacists delivered quick education sessions on the green bag process to refresh and reset expectations. 

Te Whatu Ora Counties Manukau

In 2012  the pharmacist-led SMOOTH (Safer Medicines Outcomes on Transfer Home) project was launched. It demonstrated how pharmacist input at discharge is highly beneficial to patient safety and integration of care when transitioning from secondary to primary care. The SMOOTH service is now considered ‘business as usual’. It reduces preventable medication errors on discharge and associated costs, improves collaboration between health professionals in the multidisciplinary team and places emphasis on educating patients about medication changes and making sure they have access to their medications at discharge.

Key aspects of the SMOOTH service:

• identification of patients who need pharmacist input at discharge
• notification process informs medical staff which patients require the SMOOTH service
• a ‘discharge checklist’ to standardise pharmacist advice on discharge
• medicine reconciliation on the electronic discharge summary – this means that information about medicines and any discharge prescriptions are recorded accurately
• tailored patient education
• communication of any issues to primary care colleagues.

Te Whatu Ora Taranaki

Te Whatu Ora Taranaki recently implemented (in 2022) an emergency department (ED) clinical pharmacy service. The project involved working with key emergency department and pharmacy staff to find out how pharmacists can best contribute to patient care in ED and how to measure the impact of the service.

ED pharmacists are now involved in completing medication history, charting admission medicines via MedChart, providing patient education and responding to medicine information or administration queries. ED pharmacists improve transitions of care by optimising medication management, identifying issues early and communicating them to ward pharmacists and admission teams. The  team collect data daily and evaluate the results monthly, to show the impact and improvement over time. 

Te Whatu Ora Waitematā | Minimising medication-related harm through improved discharge documentation and use of a checklist

Transitions are a vulnerable time in a person’s care where poor communication can contribute to serious adverse events. Te Whatu Ora Waitematā ran a project focused on improving transitions between specialist mental health to primary care. The project team successfully implemented an improved electronic discharge summary and a preparation for discharge to general practice checklist. They were tested with several clinical teams with feedback gained from clinicians, general practitioner recipients and whaiora/patients.

The electronic discharge summary is located within the health care community mental health system. Once the summary is finalised it is sent to the nominated general practitioner. The summary auto-populates the diagnoses, medications on discharge and allergies/adverse events sections from existing clinical and medication records, reducing the risk of error if these were omitted or manually entered by the clinician.

The action points section is at the start of the letter, making it readily visible to the receiving general practitioner. This section has medication-specific sections ie, when the last prescription was issued and when the next prescription is due, dispensing instructions (if any), relevant physical health monitoring (ie, metabolic screening, specific monitoring and investigations related to prescribed medications) and other recommendations (eg, if needed in the future, what adjustments could be made to medication doses/regime and how long to continue treatment).

The checklist prompts clinicians on the process and required documentation when planning a person’s discharge to primary care. Medication-specific elements of this checklist include prompts for the clinician to identify the person’s dispensing pharmacy on the clinical front page section, to provide the person on discharge with a prescription for medications if required, and to communicate with other stakeholders as needed, eg, handover to the nominated pharmacist, GP or practice nurse.

Discharge to aged residential care

Hauora a Toi Bay of Plenty focused on the practicalities of discharging patients to aged residential care.

The day before discharge:

• Provide a complete list of regular and PRN (as needed), including the indication and duration. All medicines need to be on the prescription for compliance packaging.
• Document any changes made while in hospital. Annotate dose increase, dose decrease, stopped or changed medication.
• Consider the practicalities of accessing the medicines on discharge. Sending the prescription a day early will enable:
  • the GP/nurse practitioner to prescribe the medications on the facility’s medication chart
  • the community pharmacy to dispense into compliance packs and delivery to the care facility. The facility may be out of town and a distance from the pharmacy supplying the medicine
  • time to resolve any clinical or funding queries. Include required special authority numbers and subsidy by endorsement eg, diagnosed COPD on spirometry for newly initiated long-acting muscarinic antagonists (LAMAs).

The biggest challenge is the accuracy of the discharge prescription and ensuring that all medications are prescribed on the discharge prescription and that PRN medications have been considered and prescribed as well. Some recent examples of medications missed off include levothyroxine, aspirin, laxatives and analgesia.

Sometimes discontinued medicines remain in the medication list in the transfer of care/discharge summary which causes confusion. These need to individually be reviewed and stopped. The rationale for medication changes needs to be included on the discharge summary as the ARC facilities do not have access to this reasoning.

An ARC GP said ‘one of the most difficult problems is knowing what medications are for and duration. A prime example is dexamethasone in palliative care, which has a number of indications and is typically tapered/stopped, but not always. If we don’t know why this was started, future decisions around this are difficult.’

Bay of Plenty Community Pharmacy Group members and Medwise were supportive of improvements in the quality if the discharge summary and sending the prescription the day before discharge.

Please help encourage sending the complete medication list and prescription the day before discharge. Posters are now on display across Tauranga and Whakatane hospitals. We want all patients to receive the correct medication at the right time on admission to the care facility, and to not miss any doses.

Download the poster: Discharging to aged residential care (185KB, pdf)