1.1 Purpose of this supplement - Safety and Quality Web viewPharmaceutical Benefits Scheme Hospital...

VERSION 1

PBS Hospital Medication Chart (PBS HMC) Project:Trial and evaluation of the PBS HMCin public and private hospitals:

Phase 1 reporttechnicalsupplement

July 2016

© Commonwealth of Australia 2016This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source. Requests and inquiries concerning reproduction and rights for purposes other than those indicated above requires the written permission of the Australian Commission on Safety and Quality in Health Care, GPO Box 5480 Sydney NSW 2001 or [email protected]

Suggested citationAustralian Commission on Safety and Quality in Health Care

PBS HMC Local Management Guidelines. ACSQHC, Sydney 2016

Contents

Definitions and abbreviations 2

1 Purpose 51.1 Purpose of this supplement 6

2 Development of the draft PBS HMC for trial 72.1 Development process 8

2.2 Patient identification panel 9

2.3 Period of chart validity 9

2.4 Hospital identification 9

2.5 Prescriber details 9

2.6 Medication orders 10

2.7 Discharge prescriptions 10

3 PBS HMC evaluation methodology 113.1 Human factors evaluation 12

3.2 Hospital trial 13

4 Trial implementation 164.1 Hospital recruitment 17

4.2 Local implementation structures 18

4.3 Chart variations 18

4.4 Trial site training and support 18

4.5 Factors influencing implementation at the trial sites 19

5 Evaluation findings 215.1 Human factors evaluation 22

5.2 Hospital trial results 24

6 Changes made to chart post-evaluation 36

Appendices 39Appendix 1 – PBS HMC approved for trialling 40

Appendix 2 – PBS HMC final for approval 41

Appendix 3 – Trial sites and sites that withdrew from the trial 44

Appendix 4 – Audit of chart safety elements – definitions and analysis 46

Appendix 5 – Safety audit outcomes 53

5.1 Private hospitals 53

5.2 Public hospital 66

Appendix 6 – Statistical analysis of safety audit outcomes 74

Pharmaceutical Benefits Scheme Hospital Medication Chart (PBS HMC) | Technical Supplement 1

Definition and Abbreviations

Term/Acronym Definition

ACSQHC Australian Commission on Safety and Quality in Health Care (the Commission).

APN Authority Prescription Number.

Approved Hospital Authority A hospital authority (for a private or public hospital) approved under section 94 of the National Health Act 1953 (or otherwise approved under that Act) to supply pharmaceutical benefits.

Approved Medical Practitioner (APM)

A medical practitioner approved under section 92 of the National Health Act 1953 to supply pharmaceutical benefits (dispensing doctor).

Approved Pharmacist (AP) A pharmacist approved under section 90 of the National Health Act 1953 to supply pharmaceutical benefits (community pharmacy).

Approved Supplier Approved Hospital Authority and Approved Pharmacist, being the only approved PBS HMC suppliers.

BD Twice a day.

Claiming Claims lodged by an approved hospital authority or an approved pharmacist for payment of PBS/RPBS claims for listed PBS/RPBS items, for PBS/RPBS eligible patients in PBS/RPBS appropriate settings only.

Closing the Gap A measure established to reduce the cost of PBS medicines for eligible Aboriginal and Torres Strait Islander people living with, or at risk of, chronic disease.

The Commission Australian Commission on Safety and Quality in Health Care.

Controlled Drug (Schedule 8 item)

A substance that should be available for use, but requires restriction of supply to reduce abuse, misuse and physical or psychological dependence as defined under the Poisons Standard 20161. These items include pharmaceutical benefits that attract a Dangerous Drug fee.

DHS The Australian Government Department of Human Services.

The Department The Australian Government Department of Health.

The Florey Institute of Neuroscience and Mental Health

Specialist research centre attached to the University of Melbourne.

GCP Good Clinical Practice.

ICH International Conference on Harmonisation.

Human factors analysis Identifies the human causes of an accident and provides a tool to assist in the investigation process and target training and prevention efforts.

Intervention log A document used to record the interventions made when reviewing use of the PBS Hospital Medication Chart.

Missed dose The omission of a dose of charted medication without a clinical reason being documented on the chart.

1 Australian Government Department of Health, Therapeutic Goods Administration. The Poisons Standard (Standard for the Uniform Scheduling of Medicines and Poisons No. 11) March 2016 https://www.legislation.gov.au/Details/F2016L00174

2 Australian Commission on Safety and Quality in Health Care

Contents


National Inpatient Medication Chart (NIMC)

The national standardised paper medication chart designed by the Commission for hospital inpatients.

NHA National Health Act 1953.

NKDA Nil known drug allergies.

NPS MedicineWise An independent, not-for-profit and evidence-based organisation providing practical tools such as medicines lists, evidence-based information, and continuing professional development educational activities, with the aim to improve the way health technologies, medicines and medical tests are prescribed and used.

NRMC National Residential Medication Chart.

“owing” prescription A prescription not yet received by a pharmacy, although the prescribed medicine has been ordered via a valid process (verbal or other valid process) and has been supplied in anticipation of receipt of the prescription.

PBS Pharmaceutical Benefits Scheme is also taken to include the Repatriation Pharmaceutical Benefits Scheme (RPBS) unless otherwise stated.

PBS HMC A national standard PBS/RPBS compliant hospital medication chart.

PBS Prescriber An Approved Medical Practitioner, participating dental practitioner, authorised optometrist, authorised nurse practitioner or authorised midwife who is approved to prescribe PBS medicines under the National Health Act 1953.

PBS Schedule Schedule of Pharmaceutical Benefits – means the pharmaceutical benefits declared under section 85 of the National Health Act 1953.

PRN Pro re nata is a Latin phrase meaning in the circumstances or as the circumstance arises. It is commonly used in medicine to mean as needed or as the situation arises.

REDCap A secure web-based application designed to support data capture for research studies.

Regulation 24 Original and repeat supplies of pharmaceutical benefits can be supplied at one time if the approved prescriber is satisfied that certain conditions apply and endorses the PBS prescription ‘Regulation 24’

RPBS Repatriation Pharmaceutical Benefits Scheme under the Veterans’ Entitlement Act 1986 includes all items on the Repatriation Schedule of Pharmaceutical Benefits and the PBS Schedule.

Safety Assessment A quantitative assessment of the safety elements of the PBS HMC based on the annual NIMC audit conducted by the Commission. The assessment allows comparison of the PBS HMC safety and quality performance against the standard NIMC used in each participating facility.

Section 90 pharmacy A pharmacy approved to provide pharmaceutical benefits under section 94 of the National Health Act 1953.

Section 94 pharmacy A pharmacy approved to provide pharmaceutical benefits under section 90 of the National Health Act 1953.


Definition and Abbreviations


Stata A software package used for statistical analysis.

Therapeutic Goods Administration

An Australian regulatory body charged with the licensing of medicinal products.

Transcription error An error that occurs when a prescriber transfers information from one place to another; for example from one chart to another, from a chart to a prescription or from a chart to a discharge summary. This includes omission of relevant information.

VTE Venous thromboembolism.

VMO Visiting medical officer.

Australian Government legislation will take effect on 1 July 2016 to enable the use of the PBS HMC nationally. The PBS HMC will be available on the Commission’s website from July in line with the recommendations made in the PBS HMC summary report. A suite of support materials designed by the Commission will also be available to assist hospital organisations implement the chart.


Purpose


1 Purpose

1.1 Purpose of this supplementThis document is the technical supplement to the PBS HMC project summary report. The supplement provides a detailed explanation of the process used to:.

develop the draft Pharmaceutical Benefits Scheme Hospital Medication Chart (PBS HMC) for trial

develop and implement the evaluation methodology modify the chart based on evaluation outcomes.

The PBS HMC was developed and evaluated by the Australian Commission on Safety and Quality in Health Care (the Commission) under a funding arrangement with the Australian Government Department of Health (the Department).

The PBS HMC is a standardised national medication chart for use in public and private hospitals. The chart allows the prescribing, administering, supply and claiming of PBS and non-PBS medicines directly from the chart without the need for a separate prescription.

The Phase one technical supplement should be read in conjunction with the PBS Hospital Medication Chart (PBS HMC) project: Phase one summary evaluation report.


Development of the draft PBS HMC for trial


2 Development of the draft PBS HMC for trial

2.1 Development processThe draft PBS HMC for trial was developed in a number of steps:

An environmental scan and literature review informed a strawman initial version based on the National Inpatient Medication Chart (NIMC) and incorporating fields required to satisfy PBS claiming requirements (see Table 1).

Stakeholder consultation with the Department, Department of Human Servcies (DHS), the PBS HMC Reference Group, jurisdictional representatives and peak bodies informed a set of modifications.

The draft chart for trial was endorsed by the PBS HMC Reference Group as suitable for trial.

Table 1: PBS and RPBS prescription requirements

Patient identification

Patient’s full name as it appears on their Medicare card

Patient’s address

Patient’s Medicare number New

Any number specified on a card, issued by the Commonwealth, as an entitlement number for a patient New

Prescriber details

Name

PBS Prescriber Number New

Contact number (mobile/pager)

Address

Signature and date

Hospital details

Hospital name

Hospital provider number New

Period of chart validityChart commenced New

‘Expiry date’ or ‘chart valid’ period New

Medicine details

PBS, RPBS or private New

Medicine and form

Dose, route and frequency

Streamlined Authority/Authority Approval Number/Authority Prescription Number New

Brand substitution not permitted New

Signature

Date of prescribing

The draft PBS HMC for trial retained key safety features of the NIMC along with required PBS fields. Details of the alterations are described in the remainder of this section.


Contents

Pharmaceutical Benefits Scheme Hospital Medication Chart (PBS HMC) | Implementation Guide 1

2 Development of the draft PBS HMC for trial

2.2 Patient identification panelAppropriate patient identification is a key safety requirement as well as a requirement to supply PBS/RPBS items. Additional fields incorporated to satisfy PBS requirements included: Medicare number Any number specified on a card, issued by the Commonwealth, as an entitlement number for the patient.

Figure 1: Patient identification panel incorporating PBS requirements

2.3 Period of chart validity The PBS HMC is only valid as a PBS or RPBS prescription if the period of chart validity is documented.

Figure 2: Chart validity – PBS HMC

2.4 Hospital identificationThe inclusion of a field for hospital provider number is also a PBS/RPBS requirement as shown in Figure 2.

2.5 Prescriber detailsFor a valid PBS/RPBS order the full prescriber details, including PBS prescriber number must appear on the chart for each prescriber as shown in Figure 3.

Figure 3: Prescriber details section – PBS HMC


2.6 Medication ordersMost PBS requirements for individual medication orders already feature in the NIMC, the key additional fields incorporated included: Start and Stop date PBS/RPBS tick box Brand substitution Authority approval number Streamlined Authority Code Authority prescription number.

The PBS HMC is designed to make the most of a number of features that make supplying and claiming PBS medicines from the chart possible. There is no need for a number of different pieces of paper normally required to supply and claim PBS medicines including: repeat forms are not required as ongoing supply

is managed differently to suit hospital workflows authority prescription forms are not required as

all eligible PBS medicines can be prescribed on the PBS HMC

schedule 8 prescription forms.

The changes to the medication panels resulted in a reduction in the number of medications that could be prescribed on the chart compared to the NIMC, from nine to seven regular medicines and from seven to five as required (PRN) medicines.

Figure 4: Medication order panels – featuring authority details

2.7 Discharge prescriptionsThe PBS HMC enables prescribing on discharge, similar to the NIMC except that eachmedication order on discharge requires a prescriber’s signature and date.

Figure 5: Discharge prescriptions PBS HMC


PBS HMC evaluation methodology


An evaluation framework was developed by the Commission in consultation with the Department. The framework was endorsed by the PBS HMC Reference Group in September 2015. The framework outlines the two main aspects of the evaluation including trialling of the draft chart and a human factors analysis.

3.1 Human factors evaluation A human factors evaluation of drafts of both the acute and long-stay versions of the PBS HMC was undertaken by The University of Queensland commencing in June 2015. The evaluation aimed to: elucidate potential usability issues associated with

the two charts recommend mitigating strategies to these issues

which could be incorporated into future iterations of each chart.

The project was specifically focused on evaluating the usability of the new PBS elements of the chart (as opposed to those that were already part of the NIMC), and their potential impact on established NIMC elements. It was beyond the scope of the project to evaluate or comment on the usability of design elements that are common to the NIMC and PBS HMC charts.

The project methods are described briefly below and detailed in a separate report.2

3.1.1 Literature review An initial literature review was conducted to familiarise the research team with the NIMC, as well as broader issues relating to the PBS, HMC design, and medication errors. The findings from the literature review were used to develop the observation and interview materials for the task analysis.

3.1.2 Task analysisGiven the multi-functionality of the PBS HMC, the research team conducted an informal task analysis to determine the tasks, functions, procedures, and potential errors associated with the use of the chart in hospital settings. This involved conducting multiple visits to hospitals participating in the PBS HMC trial, as well as to a number of hospitals that were still using the NIMC (as a comparison).

During these visits, members of the research team informally observed hospital staff performing different tasks with both the acute and long-stay versions of the chart (as well as the NIMC). Staff members experienced in using the charts were interviewed to provide feedback on the design and implementation of each chart within the hospital. Semi-structured telephone interviews with key members of the PBS HMC reference group were conducted to build upon the information gleaned from the site visits. The outcomes of the task analysis served to identify potential usability problems relating to the PBS HMC drafts, and provided a basis for the development of a set of design principles to be considered in the heuristic evaluation.

3.1.3 Expert heuristic evaluation Following a detailed briefing session, seven evaluators with a range of relevant expertise conducted a heuristic evaluation of both the acute and long-stay PBS HMC drafts.

This involved six members of the evaluation team independently identifying and documenting the potential usability issues associated with each chart, using a pre-generated list of design principles or heuristics. The seventh team member reviewed a subset of the individual reports and made additional comments. In addition, the evaluators were also invited to provide suggestions to address any of the usability problems identified. The comments of each individual evaluator were combined into a single report, which was further reviewed by five members of the team.

2 University of Queensland. Human factors evaluation of the draft PBS hospital medication charts. November 2015

Pharmaceutical Benefits Scheme Hospital Medication Chart (PBS HMC) | Implementation Guide 9

3 PBS HMC evaluation methodology


3.1.4 Limitations of the human factors evaluationThe authors of report noted that any potential human factors issues with the design of the NIMC (including any that might persist in the design of the PBS HMCs) were beyond the scope of the project. Therefore, the potential design problems noted in the heuristic evaluation should not be considered an exhaustive list of all of the potential usability problems with the charts.

The usability testing techniques were designed to reveal potential design problems, rather than design benefits. Nonetheless, several benefits were noted by the evaluation team, as well as by participants in the task analysis and these are reported.

3.2 Hospital trial 3.2.1 OverviewThe Commission conducted a trial of the PBS HMC in order to assess its suitability for implementation and to inform the implementation process. This section describes the trial design including the limitations.

The trial aimed to assess whether the PBS HMC was appropriate for use in public and private hospitals, and in pharmacies dispensing medicines for these hospitals. It also sought to identify any limitations and/or necessary constraints, to form the basis of advice to government and government regulators. It included acute and long-stay formats of the chart.

Specifically, the trial evaluated: safety and quality of PBS HMC data entries compliance with regulatory requirements in

PBS data fields financial advantages to the hospital workflow efficiency for hospitals and pharmacies.

For the chart to be considered suitable for national implementation, the outcomes from the trial needed to demonstrate an improvement in workflow efficiency; a financial advantage; and have a comparable safety profile to the NIMC.

The trial was a multi-centre, open, prospective, observational cohort design. The Trial Protocol3 was developed based on clinical trial guidelines developed by the Therapeutic Goods Administration4.

The Florey Institute Statistics and Decision Analysis platform advised regarding the data sampling and analysis and was contracted to provide assistance with creating an online REDCap5 electronic case report forms (eCRF) system. The institute also developed and implemented a statistical analysis plan for the study.

REDCap eCRF storage was designed to collect the following components: safety information performance of PBS elements of chart PBS Dispensing Data owings prescriptions transcription errors medication summaries provided on discharge.

In undertaking the quantitative assessment aspects, no formal sample size/power analysis was conducted for the study and the total chart sample size was determined based on pragmatic feasibility grounds, thus the probability of missing statistically significant findings cannot be formally evaluated.

The data was analysed by the Florey Institute using the statistics package StataTM platform, Stata. Given the limited number of hospitals involved in the trial, analysis by hospital characteristics was not undertaken.

3 Australian Commission on Safety and Quality in Health Care Trial Protocol – Trial of draft PBS HMC4 Department of Health and Ageing, Therapeutic Goods Administration. Access to unapproved therapeutic goods, Clinical trials in

Australia 2004. https://www.tga.gov.au/sites/default/files/clinical-trials-guidelines.pdf


3 PBS HMC evaluation methodology

5 A secure web-based application designed to support data capture for research studies.

K,l..//3.2.2 PBS HMC safety and qualityThe trial sought to identify: Whether the PBS HMC exhibits at least the

equivalent safety profile as the NIMC Whether the PBS HMC creates any additional

sources of error for doctors, pharmacists or nurses.

This was assessed quantitatively via: standard NIMC chart audits according to current

audit guidelines6

prospective recording by the participating hospitals of key quality measures:− transcription errors− missed doses− medication summaries on discharge.

Qualitative data regarding safety were collected via user surveys and interviews. The human factors evaluation also provided qualitative information about the safety aspects of the PBS HMC (refer to Section 5.1).

Quantitative evaluation – safety auditsTo validate the safety of the PBS HMC, three audits were conducted at each participating site. A baseline audit of the safety elements of the NIMC was completed immediately prior to the implementation of the PBS HMC at trial sites. The fields, definitions, audit criteria and analysis are described in Appendix 3. Audits of the safety elements of the PBS HMC were then completed at eight and 16 weeks following introduction of the PBS HMC and compared to baseline.

The audits were conducted by pharmacists at each of the study sites. Charts were randomly audited after dispensing. The number of charts audited was based on the number of beds. For 30 beds or more, 30 charts were audited; for less than 30 beds the number of audits was equivalent to the number of beds.

No patient-identifying data was loaded to the audit system, with each audited patient being referenced locally by his or her Medical Record Number.

Data was entered onto a PBS HMC audit spreadsheet and uploaded to the NIMC audit system. The data was analysed in the first instance using simple percentage comparisons for the three audits, examining the percentage compliance with audit rules at a chart and item level. Statistical analysis was undertaken using Stata software, with a unique identifier created for each chart based on week, site and patient information.

In the statistical analysis, analysis was conducted at the patient level and item level, using a multi-level random effect logistic regression model.

The results for patient level were reported as odds ratios with corresponding 95% confidence intervals and respective p values. For safety elements reported in the positive (e.g. route clear and correct) an odds ratio of greater than one is interpreted as there being an increased odds of the outcome in a given week compared to pre-implementation (week=0), that is the safety profile of the particular item is higher for the PBS HMC. Similarly, an odds ratio of less than one for these elements is interpreted as there being reduced odds of the outcome that is the safety profile of that particular item is lower for the PBS HMC. For safety elements reported in the negative (e.g. missed doses), the odds ratios are interpreted such that less than one represents an increased safety profile and greater than one represents a reduced safety profile for the PBS HMC.

At an item level, results were reported as incident rate ratios. Data was adjusted for the number of charts to establish the impact on the number of charts, if any, on safety.

Transcription errors and medication summaries at discharge were reported weekly by the participating hospitals.

6 Australian Commission on safety and Quality in Health Care. Guide to auditing the National Inpatient Medication Chart (NIMC), 2014 http://www.safetyandquality.gov.au/wp-content/uploads/2014/07/Guide-to-Auditing-the-NIMC-V-1.6.pdf


3.2.3 Regulatory requirements for PBS data fieldsThe trial sought to identify: Whether the PBS HMC is completed appropriately

with respect to PBS data fields Which aspects were not completed appropriately and

how the design of the PBS HMC or implementation could address this.

The PBS component audit tool was developed by the Commission to determine compliance with PBS assessment criteria. Two audits were conducted over the trial period. The results were analysed based on the number and percentage of PBS fields entered appropriately.

3.2.4 Financial advantages for hospitalsThe trial sought to identify: Whether the PBS HMC resulted in financial

advantage for hospitals Which aspects of the PBS HMC needed to be

modified to optimise these advantages.

The key measure in this regard was the number of owing prescriptions. The number of owing prescriptions outstanding each week in the trial areas was recorded in the REDCap database

3.2.5 Workflow efficiencies and utility for hospitals and pharmaciesThe trial sought to identify: Whether the PBS HMC provided any utility benefits

or disadvantage relative to the NIMC Which aspects of the PBS HMC needed to be

modified to support utility and efficiency.

An online qualitative survey was developed to assess the useability of the PBS HMC and was distributed to staff towards the end of the implementation.

3.2.6 General PBS dataGeneral PBS data was secured at the end of the trial to confirm the scope of the trial and to ensure claiming occurred according the rules for the trial (Table 2), including: Prescription numbers and types by state Drug types claimed Authority type claims Pharmacy approval types Claim rejections Patient payment types claimed Regulation 24 applied.

3.2.7 Limitations of the trial methodologyWhile the original trail design sought to achieve representation from a variety of hospitals, including public and private hospitals (Section 4.1), various logistical issues meant this was not achievable in the timeframes of the trial.

While the NIMC is a standardised chart, hospitals do make amendments to suit their operational requirements and thus, while the PBS HMC was reasonably standardised for the trial, the NIMC with which the PBS HMC was compared was not the same in every site. This had implications for implementation as described in Section 4.5 and for comparison of safety performance.


Trial implementation


4 Trial implementation

4.1 Hospital recruitmentHospitals were recruited through an expression of interest process in January 2015. Applications from interested facilities were assessed by a selection committee. Nine public and nine private hospitals met or exceeded the selection criteria and were invited to participate in the trial.

In April 2015, an issue was identified with dispensing software readiness for the trial. The issue delayed the start of the trial in private hospitals and prevented eight of the public hospital cohort from participating.

The Commission approached a number of alternative public and private hospitals to join the trial. The final participants comprise nine private and one public hospital (see Table 2).

Trial sites were required to gain ethics approval, using the protocol, prior to commencing trial of the chart. Appendix 4 includes details of all sites involved in the trial, including those that withdrew.

Table 2: Final participating trial sites

Facility name Type StateParticipating wards

No. beds in trial

Software in use

Trial start

Private Hospitals

North Shore Private Hospital, Sydney

Metro NSW Medical oncology Cardiothoracic

53 Merlin 3/08/2015

The Wesley Hospital, Brisbane

Metro QLD High dependency unit Oncology x 2 Palliative care

64 Merlin 1/06/2015

St Andrew’s War Memorial Hospital, Brisbane

Metro QLD Rehabilitation 20 Merlin 1/07/2015

St Vincent’s Private Hospital, Brisbane

Metro QLD Palliative care 30 Fred 3/08/2015

St John of God, Bendigo

Regional VIC Whole of hospital (approx. 120 beds)

130 Fred 26/08/2015

John Fawkner Private Hospital

Metro VIC Medical 17 Fred 18/10/2015

Hollywood Private Hospital, Perth

Metro WA Medical Rehabilitation

54 Fred 1/09/2015

Joondalup Health Campus, Perth

Metro WA Acute aged care Rehabilitation

52 Fred 7/09/2015

St John of God Hospital Bunbury

Regional WA Whole of hospital (approx. 180 beds)

145 Fred 14/09/2015

Public Hospitals

Peter MacCallum Cancer Centre, Melbourne

Metro VIC Whole of hospital (approx. 100 beds)

129 Merlin 25/11/2015



4.2 Local implementation structuresParticipating hospitals were requested to develop structures and operational plans to support effective implementation of the trial, including establishing an overall coordination role (trial monitor) and appropriate executive sponsorship and clinical leadership. Sites were asked to develop a local implementation plan but these plans were not required to be submitted. Sites were required to submit a final project report outlining any issues in implementation.

4.3 Chart variationsIn joining the PBS HMC trial, the trial sites agreed to use a standard chart subject to some minor changes. Requests for amendments to be made in the chart that was trialled at the participating sites were received, including:

Western Australian hospitals use a separate venous thromboembolism (VTE) chart and a different panel for this purpose in their medication chart. The Reference Group agreed to support measures that would allow them to trial the PBS HMC and continue with their VTE system.

John Fawkner Hospital had an insulin sliding scale on their existing chart and requested that this be included in the trialled PBS HMC. This was not supported by the reference group and the hospital used an additional form to support their operations in this regard.

UnitingCare Queensland use a shading system in their medication chart and requested that this be retained for the PBS HMC trial. The reference group supported this change. The Wesley Hospital and St Andrew’s War Memorial Hospital are both part of the UnitingCare Group.

Peter MacCallum Cancer Centre uses a flat layout for their chart so that all medications can be seen at all times. The reference group agreed to this format based on the complexity of the patient group at the hospital.

While the NIMC is a ‘standardised chart’, hospitals make amendments to suit their operational requirements and thus, while the PBS HMC was reasonably standardised for the trial, the NIMC with which the PBS HMC was compared was not the same in every site. This had implications for implementation as described in Section 4.5.

4.4 Trial site training and supportTo support implementation of the PBS HMC at the trial hospitals, the Commission conducted site visits to deliver information and training materials and assist the hospitals in developing operational plans.

Specific training and education programs were developed for site monitors, pharmacists, nurses and medical officers involved in the PBS HMC study.

The Commission developed an elearning module in collaboration with NPS MedicinesWise. The module was made available to all trial sites.

A suite of materials was developed to support sites to implement the chart including: PBS HMC user guide PBS HMC factsheets for prescribers, nurses

and pharmacists PBS HMC guide to auditing and data collection.

The Commission also conducted two further site visits to gather feedback and provide advice where appropriate.

The e-learning module was completed by 130 personnel at the participating trial hospitals, the majority being pharmacists (see Table 3). Use varied between participating hospitals (range one to 37 staff). Use was generally highest among hospitals that participated as a whole service, although one hospital that implemented across two wards had the highest uptake. The module was completed by about half of respondents to the staff survey, including 79% of responding pharmacists (Table 5).

Over a third of respondents to the survey indicated that they had used none of the training resources provided, including 55% of nurses and 43% of doctors. The uptake of the resources may be a limiting factor in chart implementation.

Use of the resources overall varied between participating hospitals. However, those that used the training resources generally agreed that they were valuable (87 per cent of respondents) (Figure 12).

Table 3: NPS e-learning module completion by professional group



Profession Number (%) completedMedical 14 (11)

Nursing 33 (25)

Pharmacy 78 (60)

Other 5 (4)

Total 130

Table 4: Training resources used (breakdown by profession)*

Number (%) of survey responsesDoctor (n=23)

Nurse (n=31)

Pharmacist (n=38)

TOTAL (n=92)

Fact sheets 7 (30) 6 (19) 22 (58) 35 (38)

User guide 5 (22) 6 (19) 20 (53) 31 (34)

Online training module (NPS) 6 (26) 6 (19) 30 (79) 42 (46)

None used 10 (43) 17 (55) 4 (11) 31 (34)

Other 2 (9) 9 (29) 6 (16) 17 (18)

* Question asked: “Which training resources did you use – tick all that apply”

Figure 5: Training materials acceptance (overall)

4.5 Factors influencing implementation at the trial sitesFeedback gathered during the course of the trial from site visits and the survey indicated a number of factors that affected the implementation of the PBS HMC at trial sites including: Engagement with and ‘buy-in’ from medical staff Executive engagement in the change

management process Extent of implementation – whole hospital or selected

wards Executive sponsorship and clinical leadership Degree of change experienced in moving to the PBS

HMC Uptake of training and other resources

Operational support Quality of implementation plan.



A common issue observed during the trial was poor completion of the chart’s ‘prescriber details box. Pharmacists and nurses were required to intervene to ensure prescribers completed their details and signed the box as required. The time taken to achieve a compliant chart was a limitation in realising workload benefits for the PBS HMC overall.

Implementation of prescriber education was also identified in the human factors evaluation as a potential strategy to ensure effective and safe use of the chart. In particular it was suggested that guidance at the point of prescribing (such as within the patient chart) was worth considering as medical staff may be less likely to attend training, consult a detailed user manual or use online training.



Implementation at a whole of hospital level appeared to be a facilitator for implementation. In these hospitals the NIMC charts were removed from the hospital and training was provided to all hospital employees. Whole of hospital implementation also allowed for emergency departments to be involved which was a barrier in smaller implementations as it impacted on patient flow from the emergency department. In one trial site, upon the patient’s arrival in the trial ward area, prescribers often refused to rechart until the first chart had expired, leaving patients in the trial area using two different charts. For smaller ward implementations, the number of Visiting Medical Officers (VMO’s) that were involved in prescribing made implementation particularly challenging.

Executive sponsorship and clinical leadership were also key to successful implementation, and this varied between sites. At one facility the director of nursing attended the theatre break room to answer questions about the initiative from concerned anaesthetists. At the same facility medication safety champions provided leadership at a ward level to support PBS

HMC implementation. In light of the issue regarding resistance to change and chart compliance, medical clinical leadership will likely be an important factor in implementation roll-out.

The degree of change required was greater in some hospitals and highlighted the importance of implementation planning. The nature of the NIMC in place prior to the PBS HMC trial was not necessarily consistent across all sites and thus the degree of change involved was not the same across all sites.

This was particularly evident in one trial site (Hospital4) where the transition proved difficult for prescribers. Failure to complete full process mapping in the trial ward contributed to prescribers reverting to the original NIMC chart. The survey results for this site reflected this, with 55% of respondents indicating that the PBS HMC was very different (the highest of all sites) to the NIMC previously in use (Table 6). Three quarters of respondents at this site also indicated that they would not like to see the chart continued in their hospital (Section 5.2.6).

Table 5: Comparison of PBS HMC to the NIMC previously used on the trial ward *

Number (%) of survey responses

Broadly similar

Somewhat similar

Somewhat different

Very different

Hospital 1 (n=10) 3 (30) 3 (30) 3 (30) 1 (10)

Hospital 2 (n=10) 0 (0) 4 (40) 4 (40) 2 (20)

Hospital 3 (n=5) 1 (20) 2 (40) 1 (20) 1 (20)

Hospital 4 (n=11) 2 (18) 1 (9) 2 (18) 6 (55)

Hospital 5 (n=13) 7 (54) 5 (38) 1 (8) 0 (0)

Hospital 6 (n=6) 0 (0) 2 (33) 2 (33) 2 (33)

Hospital 7 (n=19) 1 (5) 9 (47) 6 (32) 3 (16)

Hospital 8 (n=7) 2 (29) 0 (0) 5 (71) 0 (0)

Hospital 9 (n=6) 2 (33) 2 (33) 1 (17) 1 (17)

Hospital 10 (n=5) 1 (20) 3 (60) 1 (20) 0 (0)

* Question asked ‘comparing the PBS HMC to the NIMC previously used on the trial ward(s), I feel they are…’


Evaluation findings


1 Human factors evaluationIn the task analysis, interviewees reported that both the PBS HMC (short-stay) and PBS HMC (long-stay) substantially reduced the administrative burden related to the prescribing, supplying, administration, and claiming of PBS and RPBS medications. In both the task analysis and the heuristic evaluation, many potential human factors problems were identified in relation to the modifications associated with each version of the PBS HMC. However, it was also noted that there were opportunities to potentially mitigate the risks associated with some of these problems through change management strategies, process changes, improved training, and further chart design modifications. In addition, some of the modifications associated with each version of the PBS HMC represented potential improvements in usability.

5.1.1 Potential benefits of the PBS HMC modifications While the usability testing techniques employed in the project were designed to identify potential design problems, several benefits were noted by the evaluation team, as well as by participants in the task analysis.

Both the acute and long-stay versions of the PBS HMC were reported to be more efficient than the NIMC with respect to the amount of time taken to process medication orders. Users commented that changing to the PBS HMCs had saved substantial sums of money in terms of owing scripts. The charts were also reported to decrease the amount of transcribing required by prescribers, as well as other workload-reducing benefits.

Most of these suggestions have been incorporated into the final PBS HMC, refer Section 6.

5.1.2 Potential risks associated with the PBS HMC modifications In general, the PBS HMC modifications involved introducing new elements onto a complex paper-based chart with significant space constraints. This resulted in some human factors issues that may impact patient safety. These are detailed fully in the University of Queensland’s report with key examples provided below to illustrate the types of modifications that may increase the level of risk associated with using the PBS HMC:

Modifications where visual clutter has been increased (e.g. the addition of more administrative information, such as the ‘Pharmacy details’ section). These changes may result in safety-critical

information being less prominent, and hence, more likely to be missed.

Modifications that could reduce the perceptual grouping of related pieces of information (e.g. the reformatting of the “Frequency” cell in the VTE prophylaxis section (acute chart) reduced its perceptual connection to the corresponding administration section; and the removal of the bold line between the mechanical and chemo prophylaxis cells in the acute chart may mean that the division between these sections is less clear).

Modifications in which the space to hand-write information has been decreased (hence potentially decreasing the legibility and prominence of the handwritten information).

Modifications in which font sizes have been decreased (potentially decreasing the legibility and prominence of this information).

Modifications that are likely to increase the number of medication charts required for some patients. This may have safety consequences such as increasing the risk of errors when setting up each new chart, and also errors when chart users have to search through more charts for safety-critical information.

Modifications that may increase the chance of column or row shift errors when using the charts (e.g. the removal of the vertical bold line in the administration section for regular medicines).

5.1.3 Possible mitigation strategies to minimise potential risks associated with the PBS HMC changes Potential mitigation strategies are summarised below and described in more detail in the task analysis and heuristic evaluation sections of the Queensland University report. These strategies are untested suggestions.

As experienced in the hospital trial, the task analysis yielded reports of numerous compliance problems associated with completing the charts as intended. The researchers considered that there may be circumstances in which some chart users know what action they are supposed to take but nonetheless fail to take it. Potential reasons for this may include memory lapses and deliberate refusal to take the action because it is not viewed as being of sufficient value. One way of addressing these issues could be to develop persuasive communication interventions, in which the goal is to convince chart users of the value of the actions they are being asked to perform.

These suggestions will be considered in the ongoing implementation of the PBS HMC, including


5. Evaluation findings

the review of the current communication and educational materials.

Table 6: Strategies to mitigate risks associated with PBS HMC changes

Type of strategy Examples Benefits

Process strategies Substitute hand written information with pre-printed information e.g. hospital details, prescriber details, adverse reactions/allergies.

Information more legible Increase efficiency Reduce transcription errors.

Training strategies Include prompts on the chart itself. Guidance is readily available at the point of chart use

Useful strategy for time poor medical staff.

Provide “quick start” guides at the point of prescribing/administration (ie in patient charts).

Guidance is readily available at the point of chart use

Useful strategy for time poor medical staff.

Use of animations/videos in training materials.

Requirements are practically demonstrated.

Use of completed charts to highlight common errors.

Education is targeted to support awareness of common errors (efficient).

Specifically educate regarding the value of the changes.

Users are more likely to make change if they appreciate the benefits.

Design strategies Reorganise the chart structure to more effectively reflect the hierarchy and structure of tasks to be performed using the chart.

Usability will be enhanced by matching the chart design to workflow.

Positioning and formatting changes to highlight critical information (e.g, increasing font size where appropriate, reserve the most eye-catching colours on the chart for only the most critical information).

Increase the salience of safety-critical information and contributes to reduced risk of errors/omissions.

Repositioning less safety-critical information into less conspicuous locations (e.g. moving the Prescriber details section to below the Medicines taken prior to presentation to hospital section on Page 1).

Decrease the salience of non-safety-critical information and optimises completion of safety critical information.

Use border formatting and colour for effectively (e.g. all areas for the prescriber to complete could be shaded with a given colour).

Improve perceptual organisation.

Make more effective use of shading and border formatting.

Reduce potential row and column shift errors and improve the perceptual grouping of related information.

Increase the space to handwrite and by increase font size, where possible.

Increase the legibility of safety-critical chart elements.


5.2 Hospital trial results5.2.1 Scope of the trialPBS data collected during the initiative was designed to confirm the scope and fidelity of the project, and to provide a general overview of the nature of the prescriptions and prescribers involved.

A total of 27 112 prescriptions were dispensed during the trial. Approximately 39% of these were from trial sites in Victoria, 34% from trial sites in Western Australia and 21% from sites in Queensland. The single New South Wales site accounted for less than 6% of the prescriptions dispensed.

Table 7: Prescriptions dispensed using the PBS HMC by participating hospitals

Site

No. PBS or RPBS

prescriptions dispensed (%)

Dispensing pharmacies

Hospital 1 1522

1522 (5.6) 1

Hospital 2 5333

Hospital 3 137

Hospital 4 179

5649 (20.8) 3

Hospital 5 8408

Hospital 6 468

Hospital 7 1900

10 776 (39.7) 3

Hospital 8 696

Hospital 9 2281

Hospital 10 6188

9165 (33.8) 3

Total 27 712 10

Table 8: Pharmacy approval type

Pharmacy approval type

No. PBS or RPBS

prescriptions dispensed

No. pharmacies

0 (Section 90) 10 691 4

H (Section 94) 15 121 5

Y (Public) 1900 1

Total 27 712 10

Table 9: Type of approved prescribers involved in the trial

Type of approved prescriber

No. PBS or RPBS


Unknown 8

Dental 9

Medical 27 692

Nurse practitioner 3

Total 27 712



Table 10: Categories of patients

Patient category (code)

No. PBS or RPBS


Concession safety net (C0) 4834

Concession (C1) 10 628

General safety net (G1) 1430

General non-safety net (G2) 7539

Repat safety net (R0) 885

Repat non safety net (R1) 2390

Unknown (UK) 6

Total 27 712

The trial design excluded a number of medications, including human growth hormone, IVF and methadone substitution programs. No claims were received for PBS medicines covered by these schemes7. Closing the Gap (CTG) claims were also not included in the scope of the trial, and the PBS data confirms that no CTG claims were received.

All claims were made through Channel B – PBS Online claiming and no rejections were recorded through the course of the initiative.

Table 11: Total prescriptions dispensed and total number of prescribers

PBS HMC chart duration (months)

No. prescriptions

dispensedNo.

prescribers

1 month 22 404 591

4 months 5059 52

12 months 249 9

Total 27 712 652

Table 12: Drug type dispensed by PBS group

Drug type (PBS group)

Prescriptions dispensed

No.

Highly specialised drugs community access (CA)

10

Efficient funding of chemotherapy related benefits (CT)

10

Dental (DT) 9

Extemporaneous (EP) 17

General (GE) 25 406

Highly specialised drugs public hospital(HB)

79

Highly specialised drugs (HS) 8

Efficient funding for chemotherapy private clinic / private hospital(IN)

1971

Palliative care (PL) 33

Repat – Section 1 (R1) 165

Repat unlisted (RN) 4

27 712

5.2.2 Audit and survey data collectedTable 13 summarises the data collected in the trial sites during the three audit periods in terms of number of patients, number of charts and number of medication items audited. A total of 790 patients had their medication charts reviewed across the three audits, involving 1428 charts and 11 223 medication items.

The post-implementation staff survey was completed 92 staff, including 38 pharmacists, 31 nurses and 23 doctors (Table 14).

Individual reports from each hospital were also analysed in terms of the issues encountered.

The sources of data were analysed and integrated to address the four research areas. The data was also cross-referenced as appropriate to the findings of the human factors evaluation.

7 Human growth hormone, IVF and methadone substitution funding arrangements have subsequently changed, refer to www.pbs.gov.au for further information.


Table 13: Chart audits conducted during the trial (by participating site)

HospitalAudit Timing

Patient CountTotal Chart count Short Stay Long Stay Item count

Hospital 1 Baseline 60 31 0 385

8 weeks 62 30 0 466

16 weeks 55 30 0 400


8 weeks 47 30 0 408

16 weeks 55 30 0 486


8 weeks 39 10 5 280

16 weeks 31 8 7 203


8 weeks 29 0 9 180

16 weeks 35 0 11 223


8 weeks 75 15 15 472

16 weeks 73 17 13 426


8 weeks 29 17 0 252

16 weeks 23 15 0 196


8 weeks 51 30 0 358

16 weeks 49 30 0 352


8 weeks 57 30 0 335

16 weeks 90 51 3 794


8 weeks 55 30 0 339

16 weeks 49 27 0 323


8 weeks 44 30 0 298

16 weeks 45 30 0 307

Totals Baseline 435 217 50 3925

8 weeks 488 222 29 3388

16 weeks 505 238 34 3910

Total 1428 677 113 11 223


Table 14: Hospital staff survey responses (breakdown by hospital and profession)

Level Participation

Number of survey responsesFacility name Doctor Nurse Pharmacist TOTALHospital 1 2 wards 2 5 3 10

Hospital 2 1 ward 2 0 3 5



Hospital 5 Whole hospital 4 6 3 13



Hospital 8 2 wards 3 1 3 7

Hospital 9 2 wards 1 2 3 6


Total 23 31 38 92

5.2.3 Findings – safety and qualityThe evaluation with respect to safety outcomes of the PBS HMC chart relative to the NIMC sought to provide an overarching check of relative safety and did not attempt to attribute any observed changes to particular features of the charts.

The data from the audits was analysed initially based on the number and percentage of fields entered appropriately for the various categories. The complete results are shown in Appendix 4.

The statistical analysis comparing safety performance for various elements of the PBS HMC at weeks eight and 16 of implementation with the NIMC at pre-implementation (week=0) is shown in Appendix 5.

The data gathered indicates that overall behaviours relating to the prescribing of medicines on medication charts did not vary from the NIMC to the PBS HMC at trial sites.

At a patient level, certain elements indicated a statistically improved performance such as “patient identification”. However, the baseline measured just 13% and increased to 34% during the trial. This is in line with the average performance of hospitals as measured in the NIMC audit 20148. The implementation of the chart could reasonably have affected this element with the increased level of education and training. It is interesting to note that the performance of this element did not continue to improve at week 16 perhaps demonstrating the limited impact of education as an intervention.

Analysis at an item level indicated a statistically improved performance for some elements (route clear and correct, pharmacy annotation, missed doses, frequency matches administration) but this was not consistent at week eight and 16. At an item level there were no statistically significant reductions in safety performance for the elements analysed.

8 http://www.safetyandquality.gov.au/wp-content/uploads/2015/10/NIMC-2014-National-Audit-Report.pdf


While accepting the limitations of the audit methodology, the PBS HMC appears at least as safe as the medication charts previously in place at each of the trial sites. This is supported by the site reports, which did not identify any medication incidents associated with the PBS HMC, and by the qualitative feedback.

As expected, a reduction in transcription errors was observed in the prospective recording of transcription errors (Figure 7).

There was no change in the provision of medication summaries at discharge (Figure 8). It was anticipated at the outset of the trial that administrative time would be redistributed from the management of owings. The provision of accurate medication summaries at discharge is labour intensive but a key part of clinical service to patients. Pharmacies and hospitals involved in the trial provided optimal numbers of medication summaries prior to commencing the trial and did not benefit in this way.

Figure 7: Trends in transcription errors

Note: Baseline data was not available for this measure.

Figure 8: Trends in provision of medication summaries at discharge



5.2.4 Findings – Regulatory requirements for PBS data fieldsTable 15 shows the results of the two audits of PBS fields conducted at eight and 16 weeks.

The patient identification fields were well completed at both audits, as were the discharge medication orders. Fields not well completed included prescriber details, which is a new requirement for prescribers and frequently omitted according to nursing and pharmacy staff who spent considerable time following up these details.

Medicine order details that were not well completed included: The strike through for PBS/RPBS/Private The order start and stop dates (in particular the stop

date); The date of prescribing.

It should be noted that the audits took place after dispensing from the PBS HMC and does not reflect the high level of prescriber non-compliance reported in the clinician survey (Section 5.2.6).

Table 15: PBS fields audit outcomes

Patient identification compliant Y or NReview 1(8 weeks)

Review 2(16 weeks)

Patient’s full name (as it appears on their Medicare card) 98.7% 99.6%

Patient’s address 100.0% 100.0%

Patient’s Medicare number 100.0% 100.0%

Any number specified on a card, issued by the Commonwealth, as an entitlement number for the patient

100.0% 100.0%

Prescriber details compliant Y or NName 96.1% 93.6%

PBS prescriber number 86.7% 86.9%

Contact number (mobile / pager) 74.7% 66.0%

Address 78.3% 64.1%

Signature and date 95.6% 90.9%

Period of chart validity compliant Y or NChart commenced 79.4% 77.3%

‘Expiry date’ or the ‘Chart valid’ period (1, 4 or 12 months) 73.9% 70.1%


Medicine order details compliant Y or NReview 1(8 weeks)

Review 2(16 weeks)

PBS, RPBS or private? (strike through) 37.6% 36.4%

Medicine and form 100.0% 100.0%

Dose 100.0% 100.0%

Route 100.0% 100.0%

Frequency 100.0% 100.0%

Order Start date 83.9% 79.3%

Valid for duration or stop date ticked 48.3% 41.8%

Streamlined Authority Code 100.0% 100.0%

Authority information clear and correct 100.0% 100.0%

Brand substitution 100.0% 100.0%

Signature 98.3% 96.9%

Date of prescribing 73.8% 67.3%

Discharge compliant Y or N

Continue on discharge 100.0% 100.0%

Dispense 99.4% 99.1%

Duration 98.9% 98.9%

Quantity 99.4% 99.1%

Signature 100.0% 100.0%

Date 99.4% 98.4%



5.2.5 Findings – Financial advantagesWith the PBS HMC enabling prescribing and claiming of PBS medicines directly from the chart, the reduction of owing prescriptions was an anticipated outcome of the trial (Figure 9). The figure for owing prescriptions did not reach zero for two main reasons:

1. A number of trial wards had a two chart system in place;

2. Incomplete charts reaching pharmacy.

Figure 9: Trend in owing prescriptions

5.2.6 Findings – Workflow efficiencies and utility for hospitals and pharmacies The survey distributed to clinicians in the participating wards sought to establish their perceptions about the utility of the PBS HMC as well as specific comments and recommendations for amendments to improve utility. There was considerable variability between hospitals, reflecting some of the implementation issues (Section 4.5). Given the small number of respondents per participating hospitals, only aggregated results are presented. Responses from the participating public site accounted for 20% of responses; comparison with private hospital responses are noted as applicable.

Survey responses indicate that the PBS HMC had a positive impact on the supply of medicines to wards and on the paperwork involved in supplying PBS medicines (Figure 10). Pharmacists and doctors were more positive than nursing staff (Table 20, 21), however comments from nurses indicated considerable difficulty in achieving high compliance in chart completion amongst doctors, which is likely to be a significant factor in their response. Staff from the public hospital were more positive about the changes (79% broadly or somewhat positive) compared to 53% in the private hospitals.

Figure 10: Impact of the PBS HMC


Table 16: Impact of the changes in how medicines are supplied in trial wards, by profession*


Doctor(n=23)

Nurse(n=31)

Pharmacist (n=38)

TOTAL(n=92)

Broadly positive 6 (26) 3 (10) 10 (26) 19 (21)

Somewhat positive 9 (39) 8 (26) 17 (45) 34 (37)

No impact 5 (22) 10 (32) 3 (8) 18 (20)

Somewhat negative 2 (9) 7 (22) 8 (21) 17 (18)

Broadly negative 1 (4) 3 (10) 0 (0) 4 (4)

* Question asked: “The PBS HMC has changed how PBS/RPBS medicines are supplied in trial wards. How would you best describe the impact of these changes?”

Table 17: Impact of paperwork changes, by profession*


Doctor(n=23)

Nurse(n=31)

Pharmacist (n=38)

TOTAL(n=92)

Broadly positive 9 (39) 4 (13) 12 (31) 25 (27)

Somewhat positive 6 (26) 9 (29) 14 (37) 29 (31)

No impact 4 (18) 8 (26) 1 (3) 13 (14)

Somewhat negative 3 (13) 7 (22) 8 (21) 18 (20)

Broadly negative 1 (4) 3 (10) 3 (8) 7 (8)

* Question asked: “The PBS HMC introduced changes to the paperwork involved in supplying PBS/RPBS medicines. How would you best describe the impact of these changes?”

Overall, only 41% of respondents felt that the chart had been well received in their hospital (Table 21), however this was impacted considerably by the nature of the implementation, with acceptance being considerably higher in hospitals where there was a whole of hospital implementation (Figure 11 and Figure 12).

Acceptance was higher in the public hospital site (63%) compared to the combined private hospitals (36%).



Table 18: Perceptions about acceptance of PBS HMC in the trial site, by profession*


Doctor(n=23)

Nurse(n=31)

Pharmacist (n=38)

TOTAL(n=92)

Strongly agree 3 (13) 2 (7) 3 (8) 8 (9)

Agree 9 (39) 10 (32) 11 (29) 30 (32)

Neither agree nor disagree 4 (18) 6 (19) 13 (34) 23 (25)

Disagree 4 (18) 6 (19) 9 (24) 19 (21)

Strongly disagree 3 (13) 7 (23) 2 (5) 12 (13)

* In response to the query – “In my opinion the chart was well received in my hospital”

Figure 11: Perceptions about acceptance of PBS HMC in the trial site, by ward and whole hospital implementation*

*In response to the query – “In my opinion the chart was well received in my hospital”

Figure 12: Opinions regarding ongoing use of the PBS HMC in the trial site, by ward and whole hospital implementation*

* Question asked: “Would you like to see the chart continued to be used at this hospital?”


Overall 60% of respondents indicated that they would like to continue to use the chart, including 78% doctors, 66% of pharmacists and 39% of nurses (Table 19 and Figure 13).

89% of respondents from the participating public hospital supported continued use of the PBS HMC compared to 53% of respondents from the private hospitals participating in the trial.

Table 19: Opinions regarding ongoing use of the PBS HMC in the trial site, by profession*


Doctor(n=23)

Nurse(n=31)

Pharmacist (n=38)

TOTAL(n=92)

Yes 18 (78) 13 (39) 25 (66) 56 (61)

No 3 (13) 18 (58) 13 (34) 34 (37)

No response 2 (9) 0 (0) 0 (0) 2 (2)


Figure 13: Opinions regarding ongoing use of the PBS HMC in the trial site


The PBS HMC was expected to deliver efficiencies for the prescribing, supply and claiming of PBS medicines. Feedback from users of the chart indicated that the benefits of the chart were realised. 43% of doctors responding to the survey indicated that they estimated the chart to save one to three hours per week. 30% of respondents overall indicated that workload had increased during the trial, including almost half of responding pharmacists.

Common reasons for increased workload included frequent recharting due to the fewer numbers of medication orders on the chart and follow-up of doctors in relation to incorrect chart completion. The former relates to chart design and the latter to implementation. Nursing staff reported delays in receiving medicines due to lack of prescriber compliance in completing the required fields. Comments regarding the general design also related to increased clutter, which made the chart more difficult to use.



Table 20: Impact on workload, by profession*


Doctor(n=23)

Nurse(n=31)

Pharmacist (n=38)

TOTAL(n=92)

Time saved 1 to 3 hours per week 10 (43) 1 (3) 9 (24) 20 (22)



Time saved more than 10 hours per week 1 (4) 0 (0) 2 (5) 3 (3)

No change 5 (22) 18 (58) 8 (21) 31 (34)

Increased workload* 5 (22) 9 (29) 14 (37) 28 (30)

* The original question asked “Please provide an estimate of time saved per week as a result of the PBS HMC chart”. The question did not allow for a response “increased workload”. Included in the above table is a count of the number of respondent comments relating to increased workload.

The survey respondents contributed a large amount of qualitative data which has provided valuable input into the refinement of the chart. Suggestions relate commonly to the need to reduce clutter as reflected in the human factors evaluation. Common feedback pointed to the need to develop electronic medication charts.


Changes made to chart post-evaluation


Based on the findings of the human factors evaluation and the hospital trial, the chart has been systematically revised. This has involved revising each panel separately and ultimately rebuilding to form the final chart. (Appendix 2)

General design modifications include: Simplification of the structure to improve appearance

and reduce visual clutter Grouping of similar items Emphasis placed on the appearance of the clinical

sections as safety-critical aspects of the PBS HMC Alignment of sections to improve eye movement from

top to bottom of page and from left to right Reduction of space allocated to administrative

information such as authority numbers in order to release space and allow additional medication panels.

Feedback from clinicians particularly drove efforts to increase the number of medications panels and therefore reduce the increased workload associated with recharting (Table 22).

Table 22 summarises the changes made to the trial PBS HMC to achieve the final version.

Table 22: Medication panels – NIMC, Trial PBS HMC and final PBS HMC


6 Changes made tochart post-evaluation

Number of panels

Standard NIMC

(acute)

PBS HMC for trial

PBS HMC (post-trial)

Regular medicines

9 7 8

As required (PRN)

7 5 6

Table 21: Changes to PBS HMC trial chart by section

Section Chart modificationMedication panelsStart/Stop, Valid for duration Simplified to ‘Start date’

Streamline Authority Code (SAC) Combined into one field SAC/AAN – a legend is located below the references boxes on the chart

Authority Approval Number (AAN) Combined into one field SAC/AAN – a legend is located below the references boxes on the chart

PBS/RPBS strikethrough box Removed for each individual panel and centralised for easy use. Work instructions will include information on how to manage private items by exception.

Brand substitution not permitted Removed for each individual panel and centralised for easy use. Workinstructions will include information on how to manage the prescribing of specific brands by exception.

Date (signature line) Removed – date of prescribing will be the start date

Route panel Shifted to the left margin and reduced slightly in size

Dose and Frequency panel Increased in size, slight shift to the left and changes made to font size and opacity of shading


Section Chart modificationOther sectionsChart commence and chart expiry Removed – business rule will describe the final date of chart validity

Chart valid for 1, 4, 12 Slight decrease in size with recommendation to pre-print a tick in the 1 month box.

Prescribers’ details box Increased panels from 4 to 6 with recommendation to provide assistance in completing of information for prescribers such as printing address and providing stickers or stamps

Telephone orders/once only/stat orders box

Increase in the size of the telephone orders/once only/stat orders box by combining. Further increase in size possible where hospitals have a medication management plan form in place and do not require the medication reconciliation panel.

Jurisdictional authority Removed

Complete charts can be found at Appendix 2.


Appendices


Appendices

Appendix 1 – PBS HMC approved for trialling


Appendix 2 – PBS HMC final for approval

2.1 PBS HMC acute option 1


Appendices

2.2 PBS HMC acute option 2


2.3 PBS HMC acute long stay


Appendices


Appendix 5 – Safety audit outcomes

5.1 Private hospitals Patient level outcomes in private hospitals

PRIVATE HOSPITAL PATIENT LEVEL OUTCOMES 0 weeks 8 weeks 16 weeks

Total number of patients 238 221 242

Number of patients with short stay chart 188 192 208

Number of patients with long stay chart 50 29 34

Patient identification and weight

Number of medication charts included in the audit 404 437 460

Average number of charts per patient in the audit 1.70 1.98 1.90

Patient ID complete on all pages 34 76 84

% of patients with complete identification on all pages of medication chart 14.29% 34.39% 34.71%*

Weight documented on a medication chart 38 23 44

% of patients with weight documented on a Medication chart 15.97% 10.41% 18.18%

Adverse Drug Reaction (ADR) details

ADR documentation complete on all charts 171 173 186

% of patients with complete ADR documentation on all charts 71.85% 78.28% 76.86%

Patient has previous ADR 106 96 104

% of patients with a previous ADR 44.54% 43.44% 42.98%

Similar class of medication prescribed 12 4 4

Of the patients with a previous ADR to a medication, % of patients with similar class of ADR medication prescribed

11.32% 4.17% 3.85%

If previous ADR, do all pages have ADR alert stickers in place? 47 47 47

Of the patients with a previous ADR, % of patients with ADR alert stickers in place

44.34% 48.96% 45.19%

Variable dose

No. variable dose medications 9 11 14

% of variable dose medications prescribed in variable dose section 66.67% 72.73% 71.43%


Appendices


Venous thromboembolism (VTE) prophylaxis

VTE Risk Assessment documented on any medication chart 23 25 42

% of patients with VTE Risk Assessment documented on any medication chart

9.66% 11.31% 17.36%

VTE prophylaxis prescribed 65 63 87

VTE prophylaxis prescribed in VTE section 54 54 72

VTE prophylaxis prescribed in Regular section 11 9 15

% of VTE prophylaxis orders prescribed in VTE section 83.08% 85.71% 82.76%

Warfarin

No. times patients prescribed warfarin 55 56 29

Average number of times patient prescribed warfarin 3.44 3.50 1.93

% of warfarin orders prescribed in warfarin section 27.27% 25.00% 51.72%

No. Target INR ranges documented if prescribed in Warfarin section 7 7 8

% of warfarin orders with target INR range documented in warfarin section

46.67% 50.00% 53.33%

No. Target INR ranges documented if prescribed in Regular section 2 0 0

% of warfarin orders with target INR range documented in regular section

5.00% 0.00% 0.00%

Of the warfarin orders prescribed in warfarin sections, % of warfarin orders with indication documented

60.00% 50.00% 33.33%

Warfarin education recorded 0 0 0

% of patients with warfarin education recorded 0.00% 0.00% 0.00%

Sustained release

No. Sustained release medications ordered (regular order section) 198 181 173

No. Sustained Release medications with SR box ticked 111 96 85

% of SR medications with SR box ticked 56.06% 53.04% 49.13%

Intermittent medications

No. Intermittent medications ordered 78 75 87

No. Intermittent medications ordered & boxed 68 53 72

% of administration sections boxed correctly 87.18% 70.67% 82.76%



Duplicate orders

No. Duplicated orders 4 7 0

% of patients prescribed duplicate medications with potential to harm

1.26% 3.17% 0.00%

Pharmaceutical review

Pharmaceutical review occurred 154 153 183

% of patients who had at least one pharmaceutical review documented in current medication charts

64.71% 69.23% 75.62%

Item level outcomes in private hospitals

PRIVATE HOSPITAL iTEM LEVEL OUTCOMES 0 weeks 8 weeks 16 weeks

Drug orders

Total number of drug orders 3477 3048 3364

Total number of each drug order type in the audit

Regular orders 2250 2106 2217

PRN orders 848 596 747

Stat Only orders 358 324 375

Variable orders 6 8 10

Warfarin orders 15 14 15

Each drug order as a % of total drug order

Regular orders 64.71% 69.09% 65.90%

PRN orders 24.39% 19.55% 22.21%

Stat only orders 10.30% 10.63% 11.15%

Variable orders 0.17% 0.26% 0.30%

Warfarin orders 0.43% 0.46% 0.45%

Average number of each drug order type per patient

Average number of regular orders per patient 9.45 9.53 9.16

Average number of PRN orders per patient 3.56 2.70 3.09

Average number of stat only orders per patient 1.50 1.47 1.55

Average number of variable orders per patient 0.03 0.04 0.04

Average number of warfarin orders per patient 0.06 0.06 0.06


Appendices

PRIVATE HOSPITAL iTEM LEVEL OUTCOMES 0 weeks 8 weeks 16 weeks

Drug name

Total number of drug orders with unclear name by type


PRN orders 40 18 29

Stat only orders 15 6 24


% of each drug order type with unclear name

Regular orders 2.62% 3.32% 2.62%

PRN orders 4.72% 3.02% 3.88%

Stat only orders 4.19% 1.85% 6.40%


Total number of drug orders prescribed using trade names by type






% of each drug order type prescribed using trade names

Regular orders 30.84% 30.82% 29.41%

PRN orders 23.58% 30.54% 25.17%

Stat only orders 39.39% 44.14% 38.93%



Total number of drug orders with clear name by type







PRIVATE HOSPITAL ITEM LEVEL OUTCOMES 0 weeks 8 weeks 16 weeks

% drug orders prescribed with clear name by type

Regular orders 66.53% 65.86% 67.97%

PRN orders 71.70% 66.44% 70.95%

Stat only orders 56.42% 54.01% 54.67%

Variable orders 50.00% 100.00% 100.00%

Warfarin orders 86.67% 92.86% 80.00%

Route

Total number of drug orders with clear and correct route by type






% of each drug order type with clear and correct route

Regular orders 80.62% 82.81% 83.76%

PRN orders 76.53% 74.83% 80.46%

Stat only orders 76.26% 80.25% 86.40%

Variable orders 100.00% 87.50% 100.00%

Warfarin orders 86.67% 85.71% 86.67%

Total number of drug orders with missing route by type


PRN orders 5 6 7




% of each drug order type with missing route


PRN orders 0.59% 1.01% 0.94%





Appendices


Total number of drug orders with unclear route by type






% of each drug order type with unclear route

Regular orders 17.73% 15.38% 14.12%

PRN orders 21.58% 23.32% 18.21%

Stat only orders 20.95% 13.58% 11.20%


Warfarin orders 13.33% 14.29% 13.33%

Total number of drug orders with incorrect route by type


PRN orders 11 5 3




% of each drug order type with incorrect route


PRN orders 1.30% 0.84% 0.40%




Dose

Total number of drug orders with clear and correct dose by type








% of each drug order type with clear and correct dose

Regular orders 82.31% 83.00% 82.05%

PRN orders 82.78% 84.73% 83.27%

Stat only orders 76.82% 80.56% 78.40%

Variable orders 66.67% 100.00% 100.00%

Warfarin orders 100.00% 92.86% 100.00%

Total number of drug orders with missing dose by type


PRN orders 17 7 13




% of each drug order type with missing dose


PRN orders 2.00% 1.17% 1.74%



Total number of drug orders with unclear dose by type






% of each drug order type with unclear dose

Regular orders 16.80% 13.91% 15.52%

PRN orders 14.86% 13.93% 14.59%

Stat only orders 21.51% 16.36% 20.00%




Appendices


Total number of drug orders with incorrect dose by type


PRN orders 3 1 3




% of each drug order type with incorrect dose


PRN orders 0.35% 0.17% 0.40%




Frequency

Total number of drug orders with clear frequency by type




% of each drug order type with clear frequency

Regular orders 92.76% 90.98% 91.16%

PRN orders 69.93% 73.49% 60.37%

Variable orders 83.33% 87.50% 70.00%

Total number of drug orders with missing frequency by type


PRN orders 56 36 63


% of each drug order type with missing frequency


PRN orders 6.60% 6.04% 8.43%




Total number of drug orders with unclear frequency by type




% of each drug order type with unclear frequency


PRN orders 23.47% 20.30% 31.19%


Total number of drug orders with incorrect frequency by type


PRN orders 0 1 0


% of drug order type with incorrect frequency


PRN orders 0.00% 0.17% 0.05%


Error prone abbreviations

Number of drug orders containing 1 or more error prone abbreviations by type






% of each drug order type with 1 or more error prone abbreviations

Regular orders 38% 36% 35%

PRN orders 43% 49% 47%

Stat Only orders 36% 34% 37%

Variable orders 83% 0% 40%

Warfarin orders 27% 14% 13%


Appendices


Indication documented

Total number of drug orders with indication documented by type





% of each drug order type with indication documented

Regular orders 14.44% 15.38% 13.76%

PRN orders 36.20% 34.40% 30.92%


Warfarin orders 60.00% 50.00% 33.33%

Pharmacy annotation

Total number of drug orders with pharmacist annotation present by type






% of each drug order type with pharmacist annotation present

Regular orders 62.80% 68.00% 70.05%

PRN orders 36.79% 46.31% 53.68%


Variable orders 16.67% 12.50% 10.00%

Warfarin orders 60.00% 64.29% 60.00%



Prescriber’s signature

Total number of drug orders signed by prescriber by type






% of each drug order type signed by prescriber

Regular orders 96.44% 95.39% 97.11%

PRN orders 93.16% 88.09% 92.24%

Stat only orders 67.88% 72.22% 75.73%

Variable orders 83.33% 100.00% 100.00%

Warfarin orders 100.00% 85.71% 100.00%

Prescriber’s signature clear

Total number of drug orders where prescriber name is clear by type






% of each drug order type signed by prescriber where prescriber name is clear

Regular orders 72.26% 69.79% 74.87%

PRN orders 73.92% 70.86% 75.18%

Stat only orders 68.31% 52.99% 76.41%

Variable orders 60.00% 37.50% 70.00%

Warfarin orders 86.67% 75.00% 73.33%


Appendices


Frequency matches administration times

Total number of orders where times entered match frequency by type



% of each drug order type where times entered match frequency by type

Regular orders 96.93% 95.20% 96.44%

Variable orders 83.33% 75.00% 90.00%

Ceased orders

Total number of orders ceased by type


PRN orders 68 49 73




Of the ceased medication orders audited, % of orders ceased correctly by type

Regular orders 42.07% 32.93% 18.10%

PRN orders 32.35% 30.61% 20.55%


Variable orders 0.00% 100.00% 100.00%


Doses required & administered

% of drug orders where doses administered as required by type

Regular orders 89.73% 92.31% 92.51%

Stat only orders 93.02% 97.53% 95.73%

Variable orders 100.00% 87.50% 100.00%

Warfarin orders 86.67% 85.71% 93.33%



Administration omissions

% of drug orders where one or more doses were omitted by type





PRN maximum dose

% of PRN orders with a maximum dose documented 17.45% 21.14% 22.76%

Drug ceased and ceased correctly

Total number of ceased drug orders correctly ceased 168 99 79

Ceased Regular 146 82 63

Ceased PRN 22 15 15

Ceased Stat only 0 0 0

Ceased Variable 0 2 1

Ceased Warfarin 0 0 0

% of ceased drug orders ceased correctly 40.19% 33.00% 18.46%

Drug doses required and drug doses administered

Total number of drug doses required by type





Total number of drug doses administered by type 17323 13471 16735






Appendices


Total number of drug doses administered as required 2371 2279 2434





% of drug orders where doses administered as required 90.19% 92.94% 93.01%

Total number of drug orders where one or more doses were omitted

225 166 179





% of drug orders with one or more doses omitted 8.56% 6.77% 6.84%

Total number of PRN drug orders with a maximum dose documented

148 126 170

5.2 Public hospital Patient level outcomes in public hospitals

PUBLIC HOSPITAL PATIENT LEVEL OUTCOMESNIMC

Baseline 8 Weeks 16 Weeks

Number of patients with NIMC 30 30 30

Number of patients with NIMC Long-Stay 0 0 0

Patient identification & weight

Average number of charts per patient in the audit 1.47 1.70 1.63

% of patients with complete identification on all pages of medication chart

73.33% 20.00% 93.33%

Adverse Drug Reaction (ADR) details

% of patients with complete ADR documentation on all charts 96.67% 93.33% 100.00%

% of patients with a previous ADR 43.33% 26.67% 33.33%

Of the patients with a previous ADR to a medication, % of patients with similar class of ADR medication prescribed

7.69% 12.50% 20.00%

Of the patients with a previous ADR, % of patients with ADR alert stickers in place

69.23% 0.00% 0.00%


PUBLIC HOSPITAL PATIENT LEVEL OUTCOMESNIMC

Baseline 8 Weeks 16 Weeks

Variable Dose

% of variable dose medications prescribed in variable dose section 0.00% 0.00% 0.00%

Venous Thromboembolism (VTE) prophylaxis

% of patients with VTE Risk Assessment documented on any medication chart

33.33% 16.67% 53.33%

% of VTE prophylaxis orders prescribed in VTE section 0.00% 100.00% 91.30%

Warfarin

% of warfarin orders prescribed in warfarin section 0.00% 0.00% 0.00%

% of warfarin orders with target INR range documented in warfarin section

0.00% 0.00% 0.00%

% of warfarin orders with target INR range documented in regular section

N\A N\A N\A

Sustained release

% of SR medications with SR box ticked 92.31% 58.82% 85.71%

Intermittent medications

% of administration sections boxed correctly 50.00% 50.00% 100.00%

Duplicate orders

% of patients prescribed duplicate medications with potential to harm 0.00% 0.00% 3.33%

Pharmaceutical review

% of patients who had at least one pharmaceutical review documented in current medication charts

80.00% 86.67% 93.33%

Item level outcomes in public hospitals

PUBLIC HOSPITAL – ITEM LEVEL OUTCOMES Week 0 Week 8 Week 16

Drug orders

Total number of each drug order type in the audit






Average number of each drug order type per patient


Appendices


Average number of Regular orders per patient 8.60 7.97 7.97

Average number of PRN orders per patient 4.77 3.97 3.77

Average number of Stat only orders per patient 0.30 0.00 0.00

Average number of Variable orders per patient 0.00 0.00 0.00

Average number of Warfarin orders per patient 0.00 0.00 0.00

Drug name

% of each drug order type with unclear name


PRN orders 0.70% 0.00% 1.77%



% of each drug order type prescribed using trade names

Regular orders 15.50% 28.87% 24.27%

PRN orders 10.49% 26.05% 27.43%




% drug orders prescribed with clear name by type

Regular orders 83.72% 71.13% 74.48%

PRN orders 88.81% 73.95% 70.80%




Route

% of each drug order type with clear and correct route

Regular orders 94.96% 97.07% 91.63%

PRN orders 97.20% 94.12% 92.92%




% of each drug order type with missing route




PRN orders 0.00% 0.00% 0.00%




% of each drug order type with unclear route


PRN orders 2.80% 5.88% 5.31%




% of each drug order type with incorrect route


PRN orders 0.00% 0.00% 1.77%




Dose

% of each drug order type with clear and correct dose

Regular orders 93.80% 97.91% 87.03%

PRN orders 95.80% 100.00% 95.58%




% of each drug order type with missing dose


PRN orders 0.00% 0.00% 0.00%



% of each drug order type with unclear dose


Appendices


Regular orders 3.88% 0.42% 10.46%

PRN orders 2.10% 0.00% 4.42%




% of each drug order type with incorrect dose


PRN orders 2.10% 0.00% 0.00%




Frequency

% of each drug order type with clear frequency

Regular orders 96.90% 96.23% 94.14%

PRN orders 94.41% 89.92% 79.65%


% of each drug order type with missing frequency


PRN orders 1.40% 4.20% 8.85%


% of each drug order type with unclear frequency


PRN orders 4.20% 5.88% 11.50%


% of drug order type with incorrect frequency


PRN orders 0.00% 0.00% 0.00%




Error prone abbreviations

Number of drug orders containing 1 or more error prone abbreviations by type


PRN orders 3 11 19




% of each drug order type with 1 or more error prone abbreviations


PRN orders 2.10% 9.24% 16.81%

Stat only orders NA NA NA

Variable orders NA NA NA

Warfarin orders NA NA NA

% of drug orders with 1 or more error prone abbreviations 5.61% 8.10% 11.36%

Indication documented

% of each drug order type with indication documented

Regular orders 10.85% 27.20% 21.76%

PRN orders 19.58% 31.93% 28.32%



Pharmacy annotation

% of each drug order type with pharmacist annotation present

Regular orders 82.17% 72.38% 93.31%

PRN orders 78.32% 78.99% 86.73%





Appendices


Prescriber’s signature

% of each drug order type signed by prescriber

Regular orders 100.00% 97.07% 98.33%

PRN orders 100.00% 100.00% 100.00%

Stat only orders 100.00% 0.00% 0.00%



Prescriber’s signature clear

% of each drug order type signed by prescriber where prescriber name is clear

Regular orders 87.98% 93.97% 60.43%

PRN orders 90.91% 98.32% 60.18%




Frequency matches administration times

% of each drug order type where times entered match frequency by type

Regular orders 93.41% 84.10% 92.89%


Ceased orders

Of the ceased medication orders audited, % of orders ceased correctly by type

Regular orders 97.62% 90.91% 93.94%

PRN orders 100.00% 100.00% 75.00%






Doses required & administered

% of drug orders where doses administered as required by type

Regular orders 87.21% 81.59% 97.07%

Stat only orders 100.00% 0.00% 0.00%



Administration omissions

% of drug orders where one or more doses were omitted by type

Regular orders 12.79% 17.99% 2.93%




PRN maximum dose

% of PRN orders with a maximum dose documented 21.68% 21.01% 23.01%

Drug ceased and ceased correctly

% of ceased drug orders ceased correctly 97.87% 92.68% 91.89%

Drug doses required and drug doses administered

% of drug orders where doses administered as required 87.64% 81.59% 97.07%


Appendices


Australian Commission on Safety and Quality in Health Care

Level 5, 255 Elizabeth Street, Sydney NSW 2000GPO Box 5480, Sydney NSW 2001

Phone: (02) 9126 3600 (international +61 2 9126 3600)Fax: (02) 9126 3613 (international +61 2 9126 3613)

Email: [email protected] www.safetyandquality.gov.au

1.1 Purpose of this supplement - Safety and Quality Web viewPharmaceutical Benefits Scheme Hospital...

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