Implementation of NSQHS Standard 4: Medication Safety

Bonnie TaiActing Assistant Director of Pharmacy

Initiative Coordinator for NSQHS Standard 4

2 October 2013

Metro North Hospitals and Health ServiceThe Prince Charles Hospital

The Prince Charles Hospital• 600-bed tertiary referral hospital 10km north of

Brisbane• Our services include:

– Specialised state-wide services– Cardiac and thoracic medicine and surgery– Orthopaedic joint surgery (elective) – Acute geriatrics and rehabilitative medicine – Mental health service – Palliative care– General medicine and surgery services – Emergency medicine – adults and children – Children’s inpatient services

Initial Challenges• EQuIP5 1.5.1 vs NSQHS Standard 4

– Everything is new and different!• Materials still in development• Rapid changes to information• Limited resources and guidance• Communication delay

Starting Up• Developed own gap analysis template• Gap analysis by initiative coordinators and

Pharmacy managers– Based on own interpretation of the standard – Focused primarily on hospital-wide initiatives

• Formalised governance arrangements• Regular reports to Executives and

Committees

What We Do Well• Auditing

– IHI Global Trigger Tool, prescribing & administration, NIMC, QBA, Pharmacy KPIs

• High risk medications and processes• Pharmacy services

– Medication history & reconciliation– ADR documentation

• Incidents management• Decision support tools

Our Gaps• Governance• Medication storage & handling• Pharmaceutical refrigerators and

temperature monitoring• Drug use evaluation• Clinical pharmacy services

– Weekends, ED, oncology

More Challenges• Get the message across disciplines and at

all levels• Accountabilities & responsibilities• Local needs and practice gaps• Financial constraint• Coordination and Tracking progress• Resistance in some areas• Limited knowledge among ward staff

Leading Up To Accreditation• Focused on highest priority areas• Acknowledged financial constraint and

implemented best possible interim solutions

• Medication Safety Ward Checklist– Provided local data to identify issues/barriers,

guide strategies for improvement, and track progress of interventions

• Staff education

Lesson Learnt• It is not about ticking all the boxes!• Continuous quality improvement cycle• Engage clinicians at all levels across

disciplines as early as possible• Regular communication• Documentation is crucial

In Hindsight• ACSQHC & ACHS – resources & support• Multidisciplinary leads at all levels

– Accountabilities & responsibilities– Facilitate and coordinate implementation– Clear line of communication– Strategies / interventions for local needs

• Document, document, document!