november 2011 vol. 3 medication safety bulletin · 2011-11-25 · page 4 medication safety bulletin...
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P reventing harms from medication
errors or adverse drug events
remain a top patient safety priority all
over the world. It is believed that Medica-
tion Reconciliation (MR) is one of the
effective strategies to prevent them.
What is MR?
Medication reconciliation is a formal
process in which healthcare providers
work together with patients, families and
care providers to ensure accurate and
comprehensive medication information is
communicated consistently across transi-
tions of care. Medication reconciliation
requires a systematic and comprehensive
review of all the medications a patient is
actually taking to ensure that medications
being added, changed or discontinued
are carefully evaluated. It is a component
of medication management and will
inform and enable prescribers to make
the most appropriate prescribing deci-
sions for the patient.*
In fact, MR is not a new concept or initia-
tive that healthcare professionals should
adopt or implement. It is only a part of our
usual duties & responsibilities involved in
the daily operation of patent care in order
to provide the most accurate drug
treatment to the patient.
*http://www.ismp-canada.org/medrec/
Medication Reconciliation (MR)
Vol. 3
November 2011
Steps
commonly
involved in
Medication
Reconciliation
P. 2 P. 3
Highlights on the Interna-tional Medica-tion Safety (IMS) Confer-ence 2011
P. 4
Inside this issue:
Case sharing
Case 1: Wrong drugs prescribed & administered
during hospitalization
● A 73-year-old women with
past medical history of
diabetes, hypertension, chron-
ic renal failure and chronic
heart failure was admitted due
to shortness of breath & legs
edema.
● Five medications (Candesartan, Gliclazide,
Metformin, Metoprolol & Isosorbide Dinitrate)
were wrongly transcribed from an ePR print-out
which belonged to another patient admitted
earlier and so wrong drugs were prescribed to
her.
● After taking one dose of the above medica-
tions, patient’s condition deteriorated and a
Sentinel Event case was established.
Medication Safety Bulletin
Case 2: Wrong dosage prescribed & drug omitted
during discharge
● A 40-year-old patient had been taking
Risperidone during hospitalization but the drug
was omitted during discharge. Instead, she was
prescribed with Artane® 2mg tds and 6mg nocte
only.
● The incident was discovered after the patient
had missed Risperidone and taken the wrong
dosage of Artane® for 12 days.
● After checking with the last dispensing history
and patient discharge
summary in CMS,
Risperidone 6mg nocte
and Artane® 2mg om +
nocte were prescribed to
her again.
Page 2 Medication Safety Bulletin
Steps commonly involved in Medication Reconciliation
C urrently in HA, several IT features exist in the system to support and assist in medication
reconciliation process. Nevertheless, IT is only a tool. The staff culture and knowledge are of
utmost importance. The following are the six types of features which have been incorporated in our exist-
ing system. More new features to be implemented in the IPMOE will be discussed in the next issue which
will be published in May 2012.
Verification of patient
total drug profile:
Retrieval and revision of pa-
tient total drug profile include
● *Drugs prescribed by all
specialties under
Hospital Authority (HA)
● Drugs prescribed by
private institutions or
clinics
● Over-the-counter drugs
1
* Useful features in CMS
ePR Patient Summary
It summarizes all discharge / outpatient drugs with prescrip-tion and date within last 30 days
Limitations:
It only provides the prescribing record which is not necessarily the dispensing record. Thus, both ePR & CDDH should be checked to obtain the total HA drug profile Timeline display
It shows all medication and its corresponding dosage and frequency retrieved from Corporate Dispensed Drug History (CDDH). Default is set to be one year and clinician is able to change the period to longer than one year
Medication Identification
Function
Staff is able to retrieve drug image with drug color, mark-ing, shape, etc in case there is doubt about the identifica-tion of medication
Identification of drugs:
● Collection of drug packs
from patients including
those of total drug profile
● Checking any discrepancy
on drug pack with drug
record
● In case of doubt, staff can
contact pharmacy profes-
sionals for drug confirmation
or *using medication identifi-
cation function in CMS
2
* assistance from CMS; others: manual process
Clarification with patient/ caregiver:
● Clarify with patient/ caregiver what and how the patient is actually taking the drugs listed in
the total drug profile
● Check patient’s drug compliance and identify any side effects or drug related problems
(DRPs)
3
Page 3
Steps commonly involved in Medication Reconciliation
Discontinuation/ changes of drug record:
● In case certain drug is no longer suitable patient and his caregiver should be
instructed clearly
● The discontinuation / changes should be documented in physical and *CMS clinical
note
● Any changes should be marked in drug record for better subsequent management
and unintentional repetition of drugs (Future MOE / IPMOE)
Alert
Clinician can make use of alert function to alert other healthcare professionals any change of medication due to adverse events
Limitations:
Unlike drug allergy, the alert is not subject to system check
Reminder
Clinician is able to use reminder function to remind any change of medication. The screen will be prompt-ed out when clinician opens the profile of this patient unless the reminder has expired
Dispensed Record Summary This is a print-out summary of dispensed drugs to patient with detailed instructions & precau-tions in Chinese
Limitations:
It might not provide the complete drug profile
4
Communication/ handover
with different people:
● Medication reconciliation is
needed upon each
transition of care e.g. ward
transfer, discharge home,
discharge to OAH
● Clinician needs to
communicate with (i) other
healthcare providers upon
ward transfer; and (ii)
patient/ caregiver/ OAH
staff upon discharge
● Besides face to face com-
munication, clinician can
use *some CMS functions
to assist communication
5
* Useful features in CMS
Healthcare providers:
Patient/ caregiver/ OAH staff:
Page 4 Medication Safety Bulletin
This Bulletin is prepared by the Chief Pharmacist’s Office, HAHO
T he International Medication Safety Conference 2011, organized by the Hong Kong Hospital Authority
and supported by the Hong Kong Department of Health and the Centre for Food and Drug Safety of
the Chinese University of Hong Kong, had been held successfully on 2 & 3 November. About 500 local
healthcare practitioners and overseas delegates attended this meaningful event. The International Medi-
cation Safety Network (IMSN) first held its annual meeting in Asia, hence the theme “Medication Safety –
Dawn of a New Era” was chosen for this conference. The objective of the Conference was to promote
medication safety and strengthen the safety culture among the healthcare practitioners. More importantly,
it provided a valuable platform for networking the Asian countries in enhancing medication safety, and
hence delivering quality healthcare services.
The Conference comprised both plenary and concurrent lectures as well as booth and exhibit displays.
More than 20 overseas as well as local renowned speakers were invited to share their experience and
knowledge on medication safety. This year, apart from the thematic presentations, 24 posters focusing on
strategies to enhance medication safety were also displayed.
A number of guests from China and Hong Kong were invited to
officiate the Opening Ceremony of the Conference.
From left to right:
Prof Thomas Chan; Dr P Y Lam; Mr Anthony Wu; Mr Shao Ming-li;
Mr Richard Yuen; Dr P Y Leung; Dr Joseph Lui
Both Hong Kong Hospital Authority &
Department of Health shared some local med-
ication safety and quality initiatives & measures.
In addition, several countries/ cities from Asia Pacific were
invited to share their national reporting systems and works on
medication safety. They were well received by the audience. It
was hoped that other countries/ cities would find it useful and
applicable in their own healthcare systems.
Since both western and Chinese medicines
(CM) are commonly used together in Hong
Kong nowadays in the disease management, the safe use of
CM is undoubtedly important. Thus, a speaker was invited to
share his expertise in this area.
The presentations on that day were focused on 5 themes:
(1) incident reporting & prevention in overseas countries;
(2) staff engagement;
(3) medication safety in local old aged homes;
(4) community engagement & collaboration in Hong Kong; and
(5) strategies to enhance medication safety (oral presentations of the 6 selected abstract submissions)
Highlights on the International Medication Safety (IMS) Conference 2011
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