Te Rā Haumaru Tūroro o Aotearoa
Aotearoa Patient Safety Day 2022
Te Rā Haumaru Tūroro o Aotearoa | Aotearoa Patient Safety Day 2022 was observed on 17 November.
Te Rā Haumaru Tūroro o Aotearoa
Te Rā Haumaru Tūroro o Aotearoa | Aotearoa Patient Safety Day 2022 was observed on 17 November.
The focus of our activity was on medicines at transitions of care from hospital to the community, which ties in with the World Health Organization’s theme for World Patient Safety Day this year: medication without harm.
We had three simple key messages, which we called ‘the three Ps’:
We provided two consumer resources and a digital communications pack to health care providers to promote the day.
Here is how Counties Manukau Te Whatu Ora celebrated Aotearoa Patient Safety Day on Thursday 17 November.
Here is how Counties Manukau Te Whatu Ora celebrated Aotearoa Patient Safety Day on Thursday 17 November.
We received three examples of quality improvement initiatives with a focus on reducing medication harm in transitions of care from hospital to the community. We acknowledge the work of the team in the examples and their willingness to share this mahi. These examples may be interesting or relevant for your own area of work.
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:
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.
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.
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:
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.
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.
We received the following example of a resource developed for Aotearoa Patient Safety Day by Te Whatu Ora Hauora a Toi Bay of Plenty.
Hauora a Toi Bay of Plenty focused on the practicalities of discharging patients to aged residential care.
The day before discharge:
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)
Hauora a Toi Bay of Plenty focused on the practicalities of discharging patients to aged residential care.
The day before discharge:
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)
Thank you for supporting Aotearoa Patient Safety Day 2022 and promoting this important topic.
A document outlining our rationale for using the ‘three Ps’ for medicines at transitions of care, is available to download below.