Action 4.02

The Clinical Governance Standard has specific actions relating to health service organisations’ quality improvement systems:

• Action 1.08 – quality improvement systems
• Action 1.09 – reporting
• Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for medication management.

Safe medicine use requires:

• An understanding of the risks and barriers in the medication management pathway
• Routine collection and monitoring of data to measure the performance of the medication management pathway, and act if required
• Mechanisms for learning from medication incidents and from identified risks in the medication management pathway that could jeopardise patient safety
• Mechanisms to show that the risk reduction strategies in place improve the safety and performance of medication management
• Careful planning when introducing new technology (for example, electronic medication management).

Monitor effectiveness and performance

Medication safety self-assessments are an important monitoring activity to identify structure, system and communication opportunities to proactively reduce harm and target risk mitigation strategies. Use the organisation’s quality improvement systems to identify and prioritise the organisational and clinical strategies for medication management. Use assessment tools such as Medication Safety Self Assessment® for Australian Hospitals, or other internationally or locally developed (and endorsed) tools, to self-assess all or part of the organisation’s medication management pathway. Medication Safety Self Assessment® tools are also available in specialist domains such as oncology and antithrombotic therapy, two areas of high risk for medication error and adverse events (linked to Action 4.15).

Areas to assess may include:

• Practices associated with procurement through to storage and destruction of unwanted medicines (including high-risk medicines – Action 4.15)
• Quality of, and access to, medicine-related information resources, decision support tools and documentation (for example, BPMH – Action 4.05)
• Information for patients (Actions 4.03, 4.11 and 4.12).

Use a multidisciplinary team that includes frontline members of the workforce to conduct the assessment and obtain information on barriers to managing medicines safely. Review the results and compare them with any previous baseline assessments or audits to assess the impact of medication safety strategies.

Involve patients or consumers in these self-assessments by using surveys or focus groups, or including these in the organisation’s processes for monitoring and responding to medicine-related complaints.

Other monitoring actions may include:

• Establishing a list of medicine-related indicators that reflect the organisation’s usual range of medicines and their risk, along with the performance of medication management; use validated indicators such as the National Quality Use of Medicines Indicators for Australian Hospitals
• Using failure mode and effects analysis as a (prospective) proactive and ‘preventive’ process (see information from the Institute for Safe Medication Practices and the Institute for Healthcare Improvement)
• Auditing compliance with medication safety policies and procedures – for example, the use of cognitive impairment, delirium and falls assessment tools with respect to medicine use; or completion of venous thromboembolism risk assessment
• Conducting observation audits and walk-arounds to identify where corrective action might be required when breaches, violations or practice variations are observed
• Assessing the use of technology (for example, electronic medication management)
• Monitoring the occurrence of, analysing the frequency and causes of, and reporting on, medicine-related incidents, including ADRs (related to Actions 4.07, 4.08 and 4.09)
• Capturing pharmacist interventions and using the data to identify further opportunities to improve medication management processes
• Collating feedback (including complaints) from surveys or focus groups, and the organisation’s feedback and complaints management systems
• Seeking feedback on the quality, suitability and range of the medicine-related information provided to patients (for example, leaflets, brochures, medicines lists)
• Reassessing the system (or relevant components) regularly according to local, state or territory, or national requirements.

Implement quality improvement strategies

Use local, state or territory, national and international resources to identify solutions or risk mitigation strategies that might be useful, transferable and adaptable (links to Action 4.01).

Review strategies for medication management to ensure that:

• Risks identified using the various assessment, audit, survey and feedback mechanisms are logged in the risk management system
• Actions required to deal with any problems have been developed and included
• Responsibilities have been assigned.

Tools such as Pathways for Medication Safety: Leading a strategic planning effort provide guidance on a model strategic plan for medication safety.

Eliminating error is a challenge. Strategies to reduce risks are detailed in Your High-Alert Medication List—Relatively Useless Without Associated Risk-Reduction Strategies and Common Missteps with Medication Safety: Rolling a Single Dice, Ineffective Strategies, and Unexecuted Action Plans.

Report outcomes

Report evaluation findings, adverse events and quality improvement activities to the governing body and the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to the system for medication management.

Report on trend analysis (frequency and causes) of medicine-related incidents, including ADRs.

The Clinical Governance Standard has specific actions relating to health service organisations’ quality improvement systems:

• Action 1.08 – quality improvement systems
• Action 1.09 – reporting
• Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for medication management.

Safe medicine use requires:

• An understanding of the risks and barriers in the medication management pathway
• Routine collection and monitoring of data to measure the performance of the medication management pathway, and act if required
• Mechanisms for learning from medication incidents and from identified risks in the medication management pathway that could jeopardise patient safety
• Mechanisms to show that the risk reduction strategies in place improve the safety and performance of medication management
• Careful planning when introducing new technology (for example, electronic medication management).

Monitor effectiveness and performance

Medication safety self-assessments are an important monitoring activity to identify structure, system and communication opportunities to proactively reduce harm and target risk mitigation strategies. Use the organisation’s quality improvement systems to identify and prioritise the organisational and clinical strategies for medication management. Use assessment tools such as Medication Safety Self Assessment® for Australian Hospitals or other internationally or locally developed (and endorsed) tools, to self-assess all or part of the organisation’s medication management pathway. Medication Safety Self Assessment® tools are also available in specialist domains such as oncology and antithrombotic therapy – two areas of high risk for medication error and adverse events (linked to Action 4.15).

Areas to assess may include:

• Practices associated with procurement through to storage and destruction of unwanted medicines (including high-risk medicines – Action 4.15)
• Quality of, and access to, medicine-related information resources, decision support tools and documentation (for example, BPMH – Action 4.05)
• Information for patients (Actions 4.03, 4.11 and 4.12).

Use a multidisciplinary team that includes frontline members of the workforce to conduct the assessment and obtain information on barriers to managing medicines safely. Review the results and compare them with any previous baseline assessments or audits to determine the impact of medication safety strategies.

Other monitoring actions may include:

• Establishing a list of medicine-related indicators that reflect the organisation’s usual range of medicines and their risk, along with the performance of medication management; use validated indicators such as the National Quality Use of Medicine Indicators for Australian Hospitals.
• Using failure mode and effects analysis as a (prospective) proactive and ‘preventive’ process (see information from the Institute for Safe Medication Practices and the Institute for Healthcare Improvement)
• Auditing compliance with medication safety policies and procedures – for example, the use of cognitive impairment, delirium and falls assessment tools with respect to medicine use; or completion of venous thromboembolism risk assessment
• Conducting observation audits and walk-arounds to identify where corrective action might be required when breaches, violations or practice variations are observed
• Assessing the use of technology (for example, electronic medication management)
• Monitoring the occurrence of, analysing the frequency and causes of, and reporting on, medicine-related incidents, including ADRs (related to Actions 4.07, 4.08 and 4.09)
• Capturing pharmacist interventions and using the data to identify further opportunities to improve medication management processes
• Collating feedback (including complaints) from surveys, focus groups, and the organisation’s feedback and complaints management systems
• Seeking feedback on the quality, suitability and range of the medicine-related information provided to patients (for example, leaflets, brochures, medicines lists)
• Reassessing the system (or relevant components) regularly according to local, state or territory, or national requirements.

Implement quality improvement strategies

Use local, state or territory, national and international resources to identify solutions or risk mitigation strategies that might be useful, transferable and adaptable (links to Action 4.01).

Review the strategies for medication management to ensure that:

• Risks identified using the assessment, audit, survey and feedback mechanisms are logged in the risk management system
• Actions required to deal with any problems have been developed and included
• Responsibilities have been assigned.

Tools such as Pathways for Medication Safety: Leading a strategic planning effort provide guidance on a model strategic plan for medication safety.

Eliminating error is a challenge. Strategies to reduce risks are detailed in Your High-Alert Medication List—Relatively Useless Without Associated Risk-Reduction Strategies and Common Missteps with Medication Safety: Rolling a Single Dice, Ineffective Strategies, and Unexecuted Action Plans.

Report on outcomes

Report evaluation findings, adverse events and quality improvement activities to the governing body and the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to the system for comprehensive care.

Report on trend analysis (frequency and causes) of medicine-related incidents, including ADRs.

Examples of evidence

Select only examples currently in use:

• Results of trend analyses of incident data on medication management systems
• Results of workforce and patient experience surveys relating to medication management
• Quality measures and tools developed to evaluate medication management systems
• Reports to the highest level of governance and the workforce about the evaluation and assessment of performance of medication management systems
• Actions taken to improve the safety of medication management systems
• Evidence of risk assessments, evaluations and actions taken to implement new tools or processes for medication management (for example, implementation of electronic medication management)
• Audits of compliance with medication management policies and procedures
• Results of observation audits or walk-arounds
• Examples of action taken as a result of feedback (including complaints) from surveys or focus groups.

The Clinical Governance Standard has specific actions relating to health service organisations’ quality improvement systems:

• Action 1.08 – quality improvement systems
• Action 1.09 – reporting
• Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for medication management.

Safe medicine use requires:

• An understanding of the risks and barriers in the medication management pathway
• Routine collection and monitoring of data to measure the performance of the medication management pathway, and act if required
• Mechanisms for learning from medication incidents and from identified risks in the medication management pathway that could jeopardise patient safety
• Mechanisms to show that the risk reduction strategies in place improve the safety and performance of medication management
• Careful planning when introducing new technology (for example, electronic medication management).

Monitor effectiveness and performance

Medication safety self-assessments are an important monitoring activity to identify structure, system and communication opportunities to proactively reduce harm and target risk mitigation strategies. Use the organisation’s quality improvement systems to identify and prioritise the organisational and clinical strategies for medication management. Use assessment tools such as Medication Safety Self Assessment® for Australian Hospitals or other internationally or locally developed (and endorsed) tools to self-assess all or part of the organisation’s medication management pathway. Medication Safety Self Assessment® tools are also available in specialist domains such as oncology and antithrombotic therapy, two areas of high risk for medication error and adverse events (linked to Action 4.15).

Areas to assess may include:

• Practices associated with procurement through to storage and destruction of unwanted medicines (including high-risk medicines – Action 4.15)
• Quality of, and access to, medicine-related information resources, decision support tools and documentation (for example, BPMH – Action 4.05)
• Information for patients (Actions 4.03, 4.11 and 4.12).

Use a multidisciplinary team that includes frontline members of the workforce to conduct the assessment and obtain information on barriers to managing medicines safely. Review the results and compare them with any previous baseline assessments or audits to determine the impact of medication safety strategies.

Involve patients or consumers in these self-assessments by using surveys or focus groups, or including these in the organisation’s processes for monitoring and responding to medicine-related complaints.

Implement quality improvement strategies

Use local, state or territory, national and international resources to identify solutions or risk mitigation strategies that might be useful, transferable and adaptable (links to Action 4.01).

Review the quality improvement strategies for medication management to ensure that:

• Risks identified using the assessment, audit, survey and feedback mechanisms are logged in the risk management system
• Actions required to deal with any problems have been developed and included
• Responsibilities have been assigned.

Report on outcomes

Report evaluation findings, adverse events and quality improvement activities to the highest level of governance in the health service organisation and to the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to the system for comprehensive care.