1. Increasing Pharmacists reporting of adverse medication incidents Being Ready for new risks and Opportunities Prepared by Tim Garrett Northern Sydney Central Coast AHS

2. Aim  To improve the Health Services ability to respond to adverse medication safety incidents by increasing the number of pharmacist-generated incidents entered into the Incident Information Management System (IIMS) 1

3.  190,000 medication-related admissions per annum [2-3% all Australian admissions (2002-2008)], at a cost of $660 million per annum 1  Medication errors remain the second most commonly reported incident into the NSW Incident Information Management System (IIMS) 2 2 Nature and extent of the problem 1. Roughead, R et al. Medication Safety in Acute Care. Part 1 (2002-2008). Aus and NZ Health Policy 2009 2. NSW Department of Health and the Clinical Excellence Commission (CEC) 2009. Incident Management in the NSW Public Health System 2008: January to June. Published May 2009. 3. Cullen D, et al. The incident reporting system does not detect adverse drug events: A problem in quality assurance. Joint Commission Journal on Quality Improvement 1995; 21: 541­548.  Under-reporting of adverse medication incidents (50-96%) limits our ability to identify and respond to new risks and opportunities for safety improvement 3 Uribe, C. et al. 2002

4.  Medication related misadventure is commonplace, highly avoidable, and accounts for significant patient morbidity and wasted resources  Drug therapy is a complex and evolving part of therapeutics presenting ongoing known and unknown challenges  Healthcare systems need to be alert to new and evolving risks such as those posed by medication-related injury Strategic importance 3  Safety alert systems to help manage this risk but rely on frontline clinical staff to notify of incidents of actual or potential harm  Poor ‘compliance’ with these systems; hampers our ability to develop strategies for existing risk and limits our ability to anticipate, or respond to new challenges

5. Aim  To improve the Health Services ability to respond to adverse medication safety incidents by increasing the number of pharmacist-generated incidents entered into the Incident Information Management System (IIMS) 4 Why Pharmacists?  Pharmacists' interventions to improve patient outcomes are widely accepted by the profession as a cornerstone of clinical practice, 4 and are effective at improving patient and organisational outcomes. 5,6  Given the scale of the problem and limited resources available the working party elected to focus on one professional group 4. Society of Hospital Pharmacists of Australia committee of Specialty Practice in Clinical Pharmacy. J Pharm Pract Res 2005; 35: 122-146 5. Dooley MJ, et al. British Journal of Clinical Pharmacology 2003; 57: 513-521. 6. National Institute for Health and Clinical Excellence Review Body for Interventional Procedures (ReBIP). Systematic review: 2007

6. Literature review, expert opinion, workshops with target user groups, drafting and version testing Planning & implementing solutions 5 Anonymous Questionnaire: Identify barriers to ‘drug incident reporting’ Project steering committee and working party established ‘Time pressures’ and ‘Difficulty with using IIMS’ were significant barriers to incident reporting

7. Planning & implementing solutions 6 Preferred option being development of a streamlined tool CCH tool to facilitate reporting into IIMS Time and IT concerns ‘key barriers’ to incident reporting Range of strategies to address these ‘key barriers’ Planning, workshops with target user groups, drafting and version testing

8. 7 Pharmacists reported interventions into IIMS Outcomes & evaluation  Increase in IIMS medication incidents from 9.8 to 97 per month  Pharmacists as a reporting group increased from 3.8% to 42%  Pharmacists represent 1.4% of combined nursing, medical, pharmacy workforce Pharmacists reported interventions CCH v IIMS  CCH reporting tool implemented Sept 08, (mean 296 reports/month)  Review panel (for CCH tool data into IIMS), feedback and reporting

9. Sustaining change  Increased pharmacist generated incidents into the CCH reporting tool and IIMS have been sustained for > 12 months  Positive feedback from pharmacists users, concept meets its planned objectives (formal evaluation planned)  Maintained regular relevant feedback (self-generated or via manager)  User confidence in data (accuracy, consistency and completeness assured via ‘peer review group ‘of all interventions)  User confidence via safety initiates and activities resulting from data which is being reported 8

10. Lessons learned  Identified key barriers to pharmacists reporting of adverse medication incidents (time and limitations with IIMS)  This project provides a cost neutral approach to improving the volume of reporting  This approach has enhanced our understanding of medication errors  Provides an opportunity to plan strategies to mitigate / eliminate future harm  Drug-related harm is a major cause of morbidity and mortality in hospitalised patients and is relevant to all health settings. 9

11. Future scope  Further evaluation is planned at 12 months to validate the perception of an improved 'intervention reporting culture' and to quantify the utility of the reporting tool  Future planned enhancement to reporting tool (web-based)  Roll out to other facilities with NSCCAHS 10 Acknowledgements  Peter Hill  David Gilbert  Diane Reeves  Pharmacy Team (Gosford/Wyong Hospitals)