Standard 4: Medication Safety Graham Bedford, Margaret Duguid Accrediting Agencies Surveyor Workshop, 11 July 2012

Standard 4:Medication Safety

Graham Bedford, Margaret Duguid

Accrediting Agencies Surveyor Workshop, 11 July 2012

Why have a standard about medication safety?

Medications are the most prevalent health therapy in Australia

Estimated 1.5million adverse medicine events annually, resulting in at least 400,000 GP visits and 140,000 hospital admissions1

Adverse medicines events associated with:2 • 38% of readmissions to hospital

• 33% ED attendances

Acute care medication errors:• 2 – 5% of drug charts contain prescribing errors3

• 5 – 18% of doses medicines administered in error3

• 18% of IV infusions administered incorrectly (>75% rate errors)4

Medication errors a major cause of patient harm

Errors are preventable

Dispensing11%

Prescribing

39%

Administering

38%

52% of prescribing errors reach the patient - Pharmacists and nurses prevent errors

Transcription

12%

Only 2% of administration errors intercepted.

Why have a standard about medication safety?

Where do errors occur ? 5

Causes of medication errors

Systems failures• Environment

- frequent interruptions – slips, lapses• Insufficient information

• Patient information, medicines information• Poorly written medication orders

• Poor design of medication forms, electronic systems

• Look-alike sound-alike names

• Similar packaging

• Poor medicines storage

Poor teamwork, communication with colleagues, patients

Lack of knowledge

Standard 4 – Medication Safety

The Medication Safety Standard describes the elements of a safe medication management system.

It requires hospitals to have in place strategies and systems known to reduce the risk of common causes of medication error.

• standardisation and systemisation of processes

• improving clinical workforce and clinician-patient communication

• using technology to support information recording and transfer

• providing better access to patient information and clinical decision support at the point of care.

Standard 4 – Medication Safety

Clinical leaders and senior managers of a health service organisation implement systems to reduce the occurrence of medication incidents, and improve the safety and quality of medicine use. Clinicians and other members of the workforce use the systems to safely manage medicines.

Two overarching Standards:• Standard 1: Governance for Safety and Quality

• Standard 2: Partnering with Consumers

Five criteria (Part 1)

1. Governance and systems for medication safety• Health service organisations have mechanisms for the safe

prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines.

2. Documentation of patient information• The clinical workforce accurately records a patient’s

medication history and this history is available throughout the episode of care.

3. Medication management processes• The clinical workforce is supported for the prescribing,

dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of medicines.

Five criteria (Part 2)

4. Continuity of medication management• The clinician provides a complete list of a patient’s medicines

to the receiving clinician and patient when handing over care or changing medicines.

5. Communicating with patients and carers• The clinical workforce informs patients about their options,

risks and responsibilities for an agreed medication management plan.

1. Governance and systems for med safety

4.1:Developing and implementing governance arrangements and organisation policies, procedures and/or protocols for medication safety, which are consistent with national and jurisdictional legislative requirements, policies and guidelines.

Why?• Systems for safe and high quality medications need

organisational support and executive and clinical leadership to be successful

• Robust clinical governance frameworks and processes for evaluation, audit and feedback are important for the improvement of medication management systems.


4.1:Developing and implementing governance arrangements and organisation policies, procedures and/or protocols for medication safety, which are consistent with national and jurisdictional legislative requirements, policies and guidelines.

What?

Identify suitable individual / group / committee to take responsibility for governance of medication safety system (4.1.1)

• Drug and Therapeutics, Management Committee

• Reporting to safety and quality governance, executive

• Terms of reference could include:

monitoring the safety and quality of medicines use in the facility

conducting interventions to improve the safety and quality

managing adverse drug reactions and medication incidents

establishing a medication safety risk register

informing staff about medicines use issues, policies etc Consumer


4.1:Developing and implementing governance arrangements (cónt’d)

What?• Incorporate medication safety into strategic and

operational plans, safety and quality risk registers (4.1.1)

• Monitor the impact of interventions

• Training programs for staff

Medication safety risks, strategies to reduce the risks

Staff attendance at training

Completing NIMC on line learning module

Completion of NPS medication safetymodules (in progress)

.


4.1:Developing and implementing governance arrangements and organisation policies, procedures and/or protocols (cont’d)

What?• Develop and implement medication policies and

procedures across the organisation (4.1.2):• Consistent with legislative requirements• Readily accessible, version control with review date• Examples:- list of medicines approved for use in the facility (formulary)

- prescribing policies and guidelines

- procedures for administering medicines, independent checking

- procedure for checking patient identification

- use of the NIMC and ancillary charts

• Audits of compliance


Source. APAC Guiding principles to achieve continuity of medication management 2005 6



4.2: Undertaking a regular, comprehensive assessment of medication use systems to identify risks to patient safety and implementing system changes to address the identified risks

Why?• Evaluation of medication management systems to identify

areas of risk, determine changes required and prioritise areas for improvement

• Ongoing monitoring needed to track changes over time and ensure that systems operate effectively



What?• Adopt, or develop, and implement processes for assessing the

safety of the medication system (4.2.1)• Use a structured tool e.g. Medication Safety Self

Assessment7

- Multidisciplinary team- Every three years

• NIMC national audit• Failure Modes Effects Analysis



What?• Respond to assessment findings to improve performance

(4.2.2)• Action plan or risk register with actions• Quality improvements implemented and evaluated

- Audits- Indicators e.g. Indicators for Quality Use of Medicines in

Australian Hospitals 7, State performance measures• Communication with workforce


4.3: Authorising the relevant clinical workforce to prescribe, dispense and administer medications

Why?• To ensure that only staff with the competence and

authority to do so can prescribe, dispense and administer medicines

• Staff work within their scope of practice


4.3: Authorising the relevant clinical workforce to prescribe, dispense and administer medications

What?• Develop a system to:

• identify areas where specific authorization is required to prescribe, dispense or administer medicines; and

• verify and maintain register/log of individual clinicians with qualifications and competencies(4.3.1)

• Review the use of the system. Identify if system breached (4.3.2)

• Identify actions to strengthen the system, address any breaches (4.3.3)


4.4: Using a robust organisation-wide system of reporting, investigating and managing change to respond to medication incidents

Why?• Medication incidents are the second most commonly

reported incidents in Australian hospital incident monitoring systems

• To learn about the safety of the medication management process by reviewing incident reports, analysing and investigating incidents causing, or with the potential to cause, patient harm.

See also Standard 1.14


4.4: Using a robust organisation-wide system of reporting, investigating and managing change to respond to medication incidents

What?

Implement a mechanism for staff to report medication incidents and for incidents to be analysed, investigated and reported to the medication safety governance group (4.4.1)

Review reports to identify trends, causes (4.4.1)• Involve clinical staff, medication sub-committee

Identify actions to reduce risk of recurrence (4.4.2)• Medication safety risk register with actions

• Safety and/or quality improvement plan

• Report to quality/patient safety committee

• Feedback to staff


4.5: Undertaking quality improvement activities to enhance the safety of medicines use

Why?• To reduce harm to patients from known risks by

implementing and measuring the effect of quality improvement activities outlined in the medication safety quality improvement plan, risk register.

• These activities may include actions recommended to address risks identified from:

• Medication incident management system, RCA reports,• State, national or international medication safety notices/alerts, • Medication Safety Self Assessments• NIMC audit.



What?• Assess the performance of the medication management

system and evaluate effectiveness of changes (4.5.1): • Indicators e.g. Indicators for Quality Use of Medicines, state

performance measures• IHI Global Trigger Tool (identify adverse medicines events and areas

for improvement in the medication management system)• Auditing implementation of recommendations, safety alerts

- Recommendations for labelling of injectable fluids, lines and medicines

- National alerts e.g. potassium, vincristine alerts- State medication safety alerts

Prescribing errors – unclear, incorrect ordersAdministration documentationPharmacists’ documentation




What?• Use information from 4.5.1 to identify further improvement activities

required to increase the safety and effectiveness of medicines use (4.5.2)

• Implement recommendations/alerts• Standardisation of work practices and products:

- Use pre-mixed solutions or preloaded syringes for injectable high risk medicines

- Standardise dosing protocols, medication checking procedures- Implement policies, procedures and workforce training to support

standardisation• Use infusion pumps with IV safety software (“smart pump” technology) and

drug libraries • Implement oral dispensers for oral liquid medicines


2. Documentation of patient information

The clinical workforce accurately records a patient’s medication history and this history is available throughout the episode of care


4.6: The clinical workforce taking an accurate medication history when a patient presents to a health service organisation, or as early as possible in the episode of care, which is then available at the point of care

Why?• The medication history is used as the basis for

therapeutic decision making, for ensuring continuity of regular medicines while a patient is in hospital and to identify adverse medicines events.

• Medication histories are often incomplete (10 – 67% have errors) and a cause of error and harm 9.


4.6: The clinical workforce taking an accurate medication history when a patient presents to a health service organisation, or as early as possible in the episode of care, which is then available at the point of care

What?• Clinicians document a “Best Possible Medication History”

by interviewing patient/carer and verifying history with at least one other source. (4.6.1)

• Clinicians trained in taking a BPMH

• Standard form with prompts to elicit history (manual/electronic)

e.g. National Medication Management Plan or equivalent


Keep the MMP together with the current NIMC Electronic system allows history to be viewed when prescribing

Clinicians can access the medication historyand clinical information required for safe prescribing at the point of prescribing (4.6.2)

Medication Management Plan supports workforce :

Taking a complete and accurate medication history (BPMH) (4.6.1)

Documenting ADRs on admission, if ADR occurs during episode of care (4.7.1)

Reconciling discrepancies between history and medication orders (4.8.1)



4.7: The clinical workforce documenting the patient’s previously known adverse drug reactions on initial presentation and updating this if an adverse reaction to a medicine occurs during the episode of care

Why?• Prevent avoidable harm from administration of a

medicines to which the patient has a known allergy or adverse reaction

• Communicate complete allergy/adverse drug reaction history to next care provider

• Contribute to post marketing surveillance of medicines


4.7: The clinical workforce documenting the patient’s previously known adverse drug reactions on initial presentation and updating this if an adverse reaction to a medicine occurs during the episode of care

What?• Clinicians obtain and document a history of allergies and

adverse drug reactions (ADRs) when patients are admitted (4.7.1)

• Reduce risk of adverse reactions (4.7.2) by:• Recording information on the medication chart (NIMC) or in

electronic record - information available when medicines are prescribed, dispensed or administered

• Updating clinical record when ADR experienced during episode of care

• Informing GP and patient in discharge documentation• Monitoring documentation through audits, indicators (Indicator 3.2

Indicators for QUM in Australian Hospitals)


4.7: The clinical workforce documenting the patient’s previously known adverse drug reactions (cont’d)

What?• System encourages and supports clinicians to report

adverse reactions:• Within in organisation for consideration by the Medication

Safety Governance Groupo Review ADRs reported and feedback information to staff in

medication safety or drug bulletins, at staff in-service session, grand rounds

• To Therapeutic Goods Administration (4.7.3)- Facility to report ADRs to TGA online - Number of ADRs reported to TGA


4.8: The clinical workforce reviewing the patient’s current medication orders against their medication history and prescriber’s medication plan, and reconciling any discrepancies (Developmental)

Why?• Studies show that 30 – 70% patients admitted to hospitals

have ≥ 1 discrepancy between medicines taken at home and medicines ordered on admission 10

• The process of reconciling medicines ordered with the medication history (BPMH) reduces by >50% the errors and adverse events that occur when care is transferred e.g. when patient admitted, transferred internally or discharged


4.8: The clinical workforce reconciling discrepancies between patient’s current medication orders and medication history

What?• Implement a formal structured process to ensure all patients admitted

to the health service receive accurate and timely medication reconciliation at admission, transfer of care and on discharge. (4.8.1)

• Procedures assigning responsibilities• Training staff• Using a standard form to document medicines reconciled

- National Medication Management Plan, equiv or e-version- NIMC Medicines taken prior to presentation section

• Prioritise patients >65 years, multiple medicines/morbidities, high risk medicines if resources limited

• Audits of rate and quality of reconciliation

37

. . .

Medication Management Plan+ implementation resources

MATCH UP Medicines Resources



3. Medication management processes

The clinical workforce is supported for the prescribing, administering, storing, manufacturing, compounding and monitoring of medicines


2.9: Ensuring that current and accurate medicines information and decision support tools are readily available to the clinical workforce when making clinical decisions related to medicines use

Why?• Lack of knowledge about medicines, lack of access to up

to date protocols/guidelines are factors known to contribute to medication errors and harm.

• The availability of decision support tools when medicines are prescribed, dispensed and administered improves the safety and quality of medicines use.


4.9: Ensuring that current and accurate medicines information and decision support tools are readily available (cont’d)

What?• Implement and maintain up-to-date medicines information

resources and decision support tools (manual or electronic) that are accessible to staff in clinical areas (at point of care) (4.9.1)

• formulary information, prescribing requirements, approval systems• reference texts• policies, protocols and guidelines• dosing calculators• drug interaction databases• guidelines for safe administration of specific medicines (eg administering

medicines via enteral tubes)• antibiotic approval systems

Hospital protocols, guidelines


SHPA Australian Injectable Drugs HandbookSHPA Don’t Rush to Crush Handbook


4.9: Ensuring that current and accurate medicines information and decision support tools are readily available (cont’d)

What?• Regular review of the use and content of clinical information and

decision support tools, to ensure that resources are current, and are endorsed for use within the organisation (4.9.2)

• Drug & Therapeutics Committee minutes/documentation• Risk assessment of drug information domain in MSSA

• Take action to improve clinical information and decision support tools where a need is identified based on review (4.9.3)

• Drug & Therapeutics Committee minutes• Examples of improvements


4.10: Ensuring that medicines are distributed and stored securely, safely and in accordance with the manufacturer’s directions, legislation, jurisdictional orders and operational directives

Why?• Product integrity is maintained, medicines stored safely,

and waste minimised

• Distribution systems are responsive to clinical demand in order for medicines to be available for patient care in a timely manner.


4.10: Ensuring that medicines are distributed and stored securely, safely (cont’d)

What?• Regular review and risk assessment of medicines storage

and distribution across the organisation.(4.10.1)

• As part of overall self assessment• Audit against policies, procedures• Observation audits and “walk arounds”• Review medication incidents


4.10: Ensuring that medicines are distributed and stored securely, safely (Cont’d)

What?• Actions to reduce risks (including confusion with look

alike sound alike names) (4.10.2)• Policies and procedures• Safe handling and disposal of S8 medicines, cytotoxic products

and hazardous substances• Use of bar code scanners (dispensing, distribution)• Physical separation of products (e.g. look-alike, sound-alike

products) • Use of Tall Man lettering (e-systems, infusion pump libraries,

shelving, packaging)• Purchasing for safety• Safer distribution systems• Staff communication, alerts,

bulletins


4.10: Ensuring that medicines are distributed and stored securely, safely (cont’d)

What?• Temperature sensitive medicines are monitored and integrity of

temperature-sensitive medicines maintained (4.10.3)• Temperatures measured, recorded, reviewed

• Workforce disposes of unused, unwanted or expired medicines, in accordance with legislative and jurisdictional requirements (4.10.4)

• S8 medicines audits• Disposal of cytotoxic products and hazardous substances (WHS

issues)• Monitoring disposal of unused, unwanted or expired medicines

(4.10.5)• Compliance with policy for disposal• Wastage


4.11: Identifying high risk medicines in the organisation and ensuring they are stored, prescribed, dispensed and administered safely

High risk medicines - PINCH (Potassium, Insulin, Narcotics(S8s),Chemotherapy, Heparin (anticoagulants)

What? • Undertake an assessment of how high risk medicines are

managed within the organisation (4.11.1)• audits• incident analysis• risk assessment tools• drug usage evaluation programs• collaborative projects• benchmarking activities.



Audits of compliance




What?• Put systems in place to minimise the risk of error (4.11.2)

• List of high risk medicines available to staff• Policies, procedures and protocols • Guidelines for prescribing, dispensing, administering and

monitoring specific high risk medicines such as anticoagulants, chemotherapy, opioids, insulin

• Pre-loaded infusions potassium, heparin• Training on awareness of high risk meds• Implement safety alerts on high risk medicines• Monitor improvement activities

4. Continuity of medication management

4.12: Ensuring a current comprehensive list of medicines, and the reason(s) for any change, is provided to the receiving clinician and the patient during any clinical handovers

Why?• 60% of patients have ≥ 3 changes during their hospital

stay 11

• Adverse drug events occur in up to 20% after discharge 11

• Patients with ≥ 1 medicine left off their discharge summary are 2.3 times more likely to be readmitted 12

• Providing an accurate list of current medicines at handover decreases medication errors and adverse events



What?• Implement and maintain a system that supports

clinicians to generate accurate and comprehensive medicines lists and explanations for changes when transferring care (4.12.1)

• Policies and procedures for medicines handover• Process of reconciling medicines list with medication history

(BPMH), discharge medicines dispensed and current medication orders (on medication chart)

• Audit of discharge summaries that include medicines list, reasons for any changes



What?• List of medicines to be continued on discharge along

with explanations of changes provided to:• Patient / carer (with counselling)(4.12.2)

- Audit clinical records (pharmacy)• Receiving clinician (4.12.3)

- Audit of discharge summaries that include medicines list, reasons for any changes

- Use of MMP and NIMC at internal transfer



What?• Increase number of patients and receiving clinicians

provided with a current list when care transferred (4.12.4)

• Communication to staff, patients

5.3 Percentage of discharge summaries that include medication therapy changes and explanations for changes

5. Communicating with patients and carers

The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.

Developmental


4.13: The clinical workforce informing patients and carers about medication treatment options, benefits and associated risks

Why?• Patients and carers require sufficient information

about treatment options to make informed choices about their medicines, and adhere to agreed treatment plans

• Failure to achieve informed agreement to the prescription can result in non-adherence


4.13: The clinical workforce informing patients and carers about medication treatment options, benefits and associated risks

What?• Implement systems that support the

provision of patient specific medicines information when medication treatment options are discussed (4.13.1)

• Consumer Medicines Information provided (documented on MMP, in clinical notes)

• Consumer information on specific medications, for example anticoagulants, chemotherapy

• Patient specific medicines information accessible in clinical areas (4.13.2)

• Hard copy or soft copy


4.14: Developing a medication management plan in partnership with patients and carers

Why?• 30 – 50% medicines prescribed for long term conditions

not used as prescribed 11

• Failure to achieve informed agreement or identify and provide support that patient needs to manage their medicines can lead to non-adherence can occur 11

• The medication management (action) plan is intended to support health professionals and patients/carers in developing strategies to manage medicines safely and achieve treatment goals


4.14: Developing a medication management plan in partnership with patients and carers

What?• Undertake assessment of the patient’s medication risks to

identify medication management issues• Use Medication Risk Identification section on National Medication

Management Plan

• Develop a medication management (action) plan that establishes treatment goals and specifies actions required to achieve medication management goals (4.14.1).

- List of medicines, allergies, administration aids- Goals of therapy, action to achieve goals

• Communicate plan to patient and with the patient’s consent to other relevant health care professionals


4.15: Providing current medicines information to patients in a format that meets their needs whenever new medicines are prescribed or dispensed

Why?• Patients and carers require information in a form they

understand and can use to assist them to use their medicines safely and effectively


4.15: Providing current medicines information to patients in a format that meets their needs whenever new medicines are prescribed or dispensed

What?• Identify medicines information resources that are in a format

that can be used and understood by patients and carers when new medicines are prescribed/supplied or medicines changed(4.15.1)

- Similar evidence to 4.14.3- Interpreter services available for CALD patients- Written information in patients own language e.g.

multilingual medicines lists • Improve medicines information provided in response to

patient feedback (4.15.2)- Action in response for complaints, patient survey

Communicating with patients and carers

Resources

Australian Commission on Safety and Quality in Health Care – Medication Safety http://www.safetyandquality.gov.au/our-work/medication-safety/

State and Territory Medication Safety Committees/sites

Clinical Excellence Commission – High risk medicines program

http://www.cec.health.nsw.gov.au/programs/high-risk-medicines

New South Wales Health Medication Management Strategy

http://www.health.nsw.gov.au/quality/medsafe/index.asp

Victorian Health Department Quality Use of Medicines

http://www.health.vic.gov.au/qum/index.htm

Western Australian Department of Health Medication Safety

http://www.safetyandquality.health.wa.gov.au/medication/index.cfm

Resources

Audit, indicators and assessment tools

Canadian Patient Safety Institute. Safer Healthcare Now! Medication reconciliation Measures

www.saferhealthcarenow.ca/EN/Interventions/medrec/Pages/measurement.aspx

Clinical Excellence Commission, NSW Therapeutic Advisory Group Inc. Medication Safety Self Assessment® for Australian Hospitals, 2007. www.mssa.cec.health.nsw.gov.au/MSSA_introduction.html

Clinical Excellence Commission, NSW Therapeutic Advisory Group Inc Medication Safety Self Assessment ® for Antithrombotic Therapy in Australian Hospitals. www.mssa.cec.health.nsw.gov.au/at2/MSSAT_introduction.html

Continuity in Medication Management – a Handbook for South Australian Hospitals November 2010. Appendix 3: SA APAC Key Performance Indicators.

www.sahealth.sa.gov.au/wps/wcm/connect/e055bd8044fd8fc2aff7efcfa5ded0ab/Pharmaceutical+Reform+Handbook+V7_Print+version.pdf?MOD=AJPERES&CACHEID=e055bd8044fd8fc2aff7efcfa5ded0ab

Institute for healthcare Improvement Failure Modes and Effects Analysis Template http://app.ihi.org/Workspace/tools/fmea/

Resources

Audit, indicators and assessment tools (Cont’d)

ISMP Canada: International Medication Safety Self Assessment for Oncology 2012 www.cec.health.nsw.gov.au/programs/mssa

NSW TAG. Indicators for Quality Use of Medicines in Australian Hospitals www.ciap.health.nsw.gov.au/nswtag/documents/publications/QUMIndicators/Manual0408.pdf

SQuIRe Plus Guide: Medication Reconciliation Audit Tool January 2012 www.safetyandquality.health.wa.gov.au/docs/squire/Medication_Reconciliation_Audit_Tool_Guidelines.pdf

Patient and carer tools and resources

ACSQHC Medication reconciliation consumer resources.

http://www.safetyandquality.gov.au/our-work/medication-safety/

Institute of Safe Medication Practices Consumer website

www.ismp.org/consumers/default.asp, www.consumermedsafety.org

NPS Better Choices, Better Health. Medicines information for consumers

http://www.nps.org.au/consumers.

WA Health Consumers’ Council: Patient First Guide (March 2012)

http://www.health.wa.gov.au/docreg/education/population/OA004305_patient_first_book.pdf

Resources

Education resources

ACSQHC Medication Management Plan Flash training tool with audio voice over

hwww.safetyandquality.gov.au/our-work/medication-safety/medication-reconciliation/nmmp/

http://whqlibdoc.who.int/publications/2011/9789241501958_eng.pdf

National Inpatient Chart On- line Training Course www.nps.org.au/health_professionals/online_learning/NIMC

NPS Better Choices Better Health National Prescribing Curriculum on line training www.nps.org.au/health_professionals/online_learning/national_prescribing_curriculum

NPS, NSW TAG Medication Safety e-Learning Modules

http://www.nps.org.au/health_professionals/online_learning

NPS Better Choices, Better Health Quality use of medicines on line training courses

http://www.nps.org.au/health_professionals/online_learning/qum

World Health Organization. Improving Medication Safety. WHO Patient Safety Curriculum Guide: Multiprofessional Edition, 2011. http://www.who.int/patientsafety/education/curriculum/en/index.html

Summary

Ensuring that competent clinicians safety prescribe, dispense and administer appropriate medicines to informed patients and carers is an essential element of safe and high quality care.

Purpose of the Standard is to improve outcomes for patients by ensuring that there is a systematic approach to medicines management and safety

Outcomes to be achieved are clear – methods to get there will vary depending on context

www.safetyandquality.gov.au

[email protected]

Summary

Ensuring that competent clinicians safety prescribe, dispense and administer appropriate medicines to informed patients and carers is an essential element of safe and high quality care.

Purpose of the Standard is to improve outcomes for patients by ensuring that there is a systematic approach to medicines management and safety

Outcomes to be achieved are clear – methods to get there will vary depending on context

www.safetyandquality.gov.au

[email protected]

References

1. Roughead EE Lexchin A. Adverse Drug Events: counting is not enough, action is needed. Medical Journal of Australia2006;184(7):315-6

2. Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. National Prescribing Service, June 2009

3. Australian Council for Safety and Quality in Health care. Second national Report of Patient Safety – Improving Medication Safety. Canberra 2002

4. Roughead EE, Semple SJ Medication safety in acute care in Australia: where are we now?. Part 1: a review of the extent and causes of medication problems 2002-2008 ANZ Health Policy 2009, 6:18

5. Leape L et al Systems analysis of adverse drug events JAMA 1995;271:35-43

6. Australian Pharmaceutical Advisory Council. Guiding principles to achieve continuity of medication management .2005

7. Clinical Excellence Commission, NSW Therapeutic Advisory Group Inc. Medication Safety Self Assessment® for Australian Hospitals, 2007. www.mssa.cec.health.nsw.gov.au/MSSA_introduction.html

8. NSW TAG. Indicators for Quality Use of Medicines in Australian Hospitals www.ciap.health.nsw.gov.au/nswtag/documents/publications/QUMIndicators/Manual0408.pdf

9. Tam V, Knowles S, Cornish P, Fine N, Marchesano R, Etchells E. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005;173(5):510-15.

10. NICE. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. London. National Institute for health and Clinical Excellence, 2007.

11. NICE. Medicines adherence – involinmg patients in decisions about prescribed medicines and supporting adherence Clinical Guideline CG 76 – January 2009

12. Stowasser DA, Stowasser M, Collins DM. A randomsied controlled trial of medication liaison services – patient outcomes. J Pharmacy Practice and Research 2002;32:133-40

Documents

Standard 4: Medication Safety Graham Bedford, Margaret Duguid Accrediting Agencies Surveyor Workshop, 11 July 2012