Documentation, provision and access to medicines-related information

Note: This action is only applicable if your healthcare service prescribes, supplies and/or administers medicines. 

Medicines are the most common treatment used in health care. Although the appropriate use of medicines contributes to significant improvements in health, medicines can also be associated with harm. Because they are so commonly used, medicines have the potential to be associated with a higher incidence of errors and adverse events when compared with other healthcare interventions.[i] Some of these adverse events are costly, and up to 50% are potentially avoidable.[ii] Errors affect both health outcomes for consumers and healthcare costs. Strengthening the systems for reducing medication errors can improve medication safety.27

Best possible medication history 

A best possible medication history (BPMH) is a list of all the medicines a patient is using at the time they receive care. The list includes the name, dose, route and frequency of the medicine, and is documented in a specific place (for example, template form or medicine record). All prescribed, over the counter and complementary medicines should be included.

The BPMH is generally obtained by a healthcare provider working within their scope of clinical practice who interviews the patient (and/or their carer); the information is confirmed, where appropriate, by using other sources of medicines information. 

Partnering with patients, carers and families

The patient is always the focus of the medication management pathway. Healthcare services should apply the principles of the Partnering with Consumers Standard, health literacy and shared decision making when developing, reviewing and implementing processes or practices within the medication management pathway.

Partnering with patients, carers and families in the management of their medicines occurs in order to support a patient’s understanding of what medicines are being proposed, or why a new medicine, or change in medicine/treatment (including a dose change or ceasing a medicine), is recommended.

Patients should be involved in setting treatment goals and supported to understand the proposed outcomes of treatment. Discussion about medicines should include: 

• Why the treatment is recommended or necessary
• If the medicine will cure their illness, or is required to control the symptoms of their chronic illness
• Duration of treatment and instructions for use
• Possible adverse effects that the medicine may have; their likelihood; and if experienced, what action should be taken.

• How do healthcare providers take a BPMH in your service?
• Where in a patient’s healthcare record is the BPMH recorded?
• How are patients encouraged to keep their own medicine list and to share this with other relevant healthcare providers?
• How is informed consent incorporated into your process for sharing the patient’s medicines list with other relevant healthcare providers on their behalf?

Develop and implement a process for healthcare providers to, within their own scope of clinical practice:

• Take a BPMH as early as possible in the episode of care
• Record this information in a patient’s healthcare record, including any adverse drug reactions 
• Use structures and systems established in the Partnering with Consumers Standard to partner with patients, carers and families in the management of medicines
• Support patients, carers and families to keep an accurate medicines list 
• Encourage patients to share their medicines list with other healthcare providers
• Share a patient’s medicines list with other healthcare providers with a patient’s consent 
• Use this information in the planning and delivery of health care
• Make template medicines lists available to patients, carers and families. 

The type and comprehensiveness of evidence used is dependent on the context of each healthcare service. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Process for obtaining and documenting a BPMH
• Evidence that BPMHs are documented in a patient’s healthcare record
• Information available to patients about the need for maintaining a current list of their medicine.

Resources

• Australian Digital Health Agency: My Health Record – information for healthcare providers on medication records in the My Health Record system. Patients can access their own record to view their own medicines list. 
• Australian Digital Health Agency: Keeping a medicines list – a useful resource which can be shared with consumers about keeping a current list of their medications. 
• World Health Organization: 5 Moments for Medication Safety resources – this tool can be applied at different levels of care and in different settings and contexts.

Partnering with patients, carers and families in the management of their medicines occurs to support a patient’s understanding on what medicines are being proposed; and why a new medicine or change in medicine/treatment (including a dose change or ceasing a medicine) is being recommended. Information on medicines that is provided to patients in a way that meets their needs and preferences should include:

• A rationale for medicine use 
• The risk to the patient of both taking and not taking the medicine 
• Instructions for effective administration 
• The expected outcome of use 
• Action to take if a problem is identified or expected outcomes do not occur.

Information on medicines provided should be relevant, evidence-based and up to date. 

Taking action when a suspected medicines-related problem is identified

When a suspected medicines-related problem is identified, healthcare providers must take action to minimise any risks of harm to patients. The specific action taken will be dependent on a healthcare provider’s scope of clinical practice. For example, a prescriber may take action by reviewing medication and potentially changing therapy, while a healthcare provider not involved in medication management may refer the patient to their prescriber or most appropriate healthcare provider or may notify them directly. In some circumstances, emergency assistance may be sought. 

Healthcare providers should ensure that the details of the occurrence and action taken are recorded in a patient’s healthcare record.

Reporting adverse events involving medicines 

Any adverse event that may have been caused by a medicine is often referred to as a ‘suspected adverse reaction’ and can involve vaccines and prescription, over the counter and complementary medicines. Suspected adverse reactions (involving medicines) that people experience that have not been previously experienced or documented are considered to be new. The healthcare service is responsible for reporting new suspected adverse events involving medicines to the TGA. Healthcare services may need to consider training for members of the workforce who are responsible for reporting adverse events (involving medicines) online to the TGA. 

Links to Actions 1.05 Incident management and open disclosure; 1.19 Scope of clinical practice and 1.20 Evidence-based care

• How do healthcare providers provide information on medicines, tailored to the patient’s needs and preferences? 
• What strategies are in place to support patients and carers to raise concerns about medicine-related risks and clarify the information they are provided?
• What processes are used to identify patients at risk of medicine-related problems or adverse events?
• What action is taken when an adverse event involving medicines is suspected?
• How are suspected adverse events (involving medicines) that are experienced by patients reported to the TGA? 

• Provide patients and carers with enough information about treatment options for them to make informed choices about their medicines, and to adhere to medicine-related treatment plans in the delivery of health care.
• Support healthcare providers to provide medicine-related information when treatment options are discussed and when treatment decisions have been made.
• Implement a process to report all new suspected adverse events involving medicines experienced by patients to the TGA and document these in the patient’s healthcare record.

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Observation of the healthcare provider accessing medicines information, or communicating with patients about medicines information in way that is tailored to their needs and preferences 
• Samples of medicine-related information resources (for example, Consumer Medicines Information, newsletters or other communication material) for the workforce, patients, carers and families that are tailored to their specific needs and meet the health literacy actions of the Partnering with Consumers Standard (for example, appropriate print size and font of the resource in the patient’s preferred language) 
• Examples of medicines lists including where medicines lists have been tailored to the specific needs of recipients (for example, the patient, community pharmacist, general practitioner and rural generalists, nurse practitioner, allied healthcare provider or school nurse)
• Communication to the workforce explaining the process for reporting suspected adverse events involving medicines to the TGA 
• Record of suspected adverse drug reaction reports submitted to the TGA
• Register of adverse events involving medicines that includes actions to address the identified risks 
• Access to tools for reporting adverse events involving medicines, for example, via the TGA website or using clinical software 
• Examples of incident records identifying potential medicine-related risks and associated actions to reduce risk or improve clinical safety outcomes
• Records of patient or carer feedback on medicine-related information provided during care. 

Resources

• Better Health Channel: Medicines information leaflets for consumers – provide important information for consumers.
• Department of Veterans’ Affairs: Veterans’ Medicines Advice and Therapeutics Education Services (Veterans’ MATES) – aims to improve the use of medicines and related health services in the veteran community.
• Healthdirect website: Provides health and medicines information for consumers. 
• Medicines information for healthcare providers can be accessed via clinical software, medicines references.
• Therapeutic Goods Administration: Reporting adverse events – information on the important role everyone can play in monitoring the safety of therapeutic goods in Australia.