Minutes of Medication Safety Expert Advisory Group MeetingThursday 14 June 2012 9.30am to 15.30pm

Eagle Room, Miramar Golf Course, Stewart Duff Drive, Rongotai, Wellington

AttendeesDwayne Crombie (Chair) Chris Cameron (CCDHB)Mary-Anne O’Rourke (Kowhai Health) Stacey Hurrell (Waitemata DHB)Nirasha Parsotam (HQSC) Rob Ticehurst (ADHB)Janet Mackay (PHARMAC) Sandra Fielding (BoP DHB)Beryl Wilkinson (Consumer) Alan Davis (Northland DHB)Mary Seddon (CMDHB) Bev Nicolls (Medical Practitioner/NMDHB)Rob Ticehurst (ADHB) David Woods (NZF)Janet Mackay (PHARMAC)

In Attendance: Gillian Bohm (HQSC), Beth Loe (HQSC), Emma Forbes (HQSC)

Invited: Desiree Kunac (NZPhVC), Sreekanth Konda (ACC), Stewart Jessamine (Medsafe) for item 6, Joanna Smith (Sapere), Preston Davis (Sapere, by phone), David Moore (Sapere, by phone) for item 7, Paula Campbell (eMM programme) for item 4

Apologies: Avril Lee (Waitemata DHB)

MinutesItem Agenda Notes/comments Action Required

Introductions The chair welcomed Sreekanth Konda to the meeting.

1. Minutes of the 19 April meeting

The minutes were approved. It was noted that the venue was Auckland

not Wellington. An update to the barcoding minutes was

provided by Mary. The trial at CMDHB involves using smart phone technology to read the patients wristband to match to lab results – the trial was being evaluated.

Update minutes (Beth)

1a. EAG disclosure ofinterests

No updates were noted at the meeting.

1b Matters arising1b item 1b Joint meeting with Peter Gow/Paul Cressey

Peter Gow had accepted the invitation to the August EAG meeting.

Paul Cressey had not responded yet.

Contact Paul Cressey to check his availability. (Beth)

1b item 1cClozapine

Letter has not been published in ANZJP yet.

An email had been sent to NZHPA Mental Health SIG members enquiring what the DHB policy was regarding pre-treatment echocardiograms.

There was a discussion around coroners

Send latest version of the letter to Beth for circulation to CMOs (Chris).

Circulate to CMOs for distribution to clinical directors of mental

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issuing recommendations in some cases where specialist advice into the recommendations would be helpful. Should the clinical directors for Mental Health and Cardiology in DHBs be sent a copy of the letter that was sent to ANZJP via the CMOs? Circulate by both post and email.

If the response to the letter being published was positive, hopefully the Australian / NZ standards could be changed to reflect the response.

health and cardiology (Beth).

1c item if Methotrexate

Discussed the letter from President of Rheumatology Association.

The alert is clearly directed at all sectors and aimed at patient safety.

The alert has triggered a reaction from clinicians in particular around strength of tablet use.

Consider whether 5mg tablets are available in preference to 2.5mg tablets.

Review funded methotrexate preparations and whether 5mg tablets are available (Janet).

2. 2a NationalMedicationChart

Chart review has been completed and final proof expected next week.

Feedback on the paediatric consultation and electronic change requests are to be sent out to participants.

Long stay pilot evaluation: some outstanding audits still to be carried out within DHBs.

Initial work has established that average number of medication charts per patient is about 2.3, average number of regular orders prescribed per patient is around 20 and an average of 28 medicines prescribed per person at any one time.

Evaluation write up expected to be completed by August meeting.

Aged residential care (ARC) chart: clinical advisory group established (includes Bev) and links to the Aged Care Association clinical leadership group which includes a number of nurses working in ARC facilities.

The project team have realised the complexities of the task and the competing interests.

2b MedicineReconciliation

Prioritisation tool: development is on-going but hampered by the ability of DHBs to generate real time data for some of the indicators.

A group of DHBs are individually testing whether their IT is able to deliver the data set in real time.

CDHB & SDHB have developed their own prioritisation tool but not just for MR but this has not been evaluated yet.

Mary mentioned that even with using their prioritisation tool, the DHB is only able to do eMR on 20% of patients so there is a need to educate RMOs regarding taking accurate medication histories and entering the information electronically in order to

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fully utilise the eDischarge Summary (eDS) facility.

2c Medicationcharting andmedicinereconciliationstandards

The standards are currently with HISO and are expected to go to HISO Board at the end of June prior to consultation.

2d eMedicineProgramme

Anton Ventnor has been appointed to the programme director position. Anton is a pharmacist with a hospital and facilitator background who has been working with Health NZ.

10 DHBs have been visited for the pre-readiness assessment.

The assessment reviews what stage DHBs are at in regard to eMedicine management, e.g. IT capability, annual plans, quality and safety, other large projects, clinical relevance etc.

Common themes identified by the DHBs to date are:o resource; both financial and project

capacityo other competing major projects (some

national) o ePharm system urgently needs upgrade

in some DHBs before any other eMM initiative

3. Patients First (Andrew Terris)

Andrew Terris (programme manager) provided an update on the projects Patients First are working on or have completed; GP2GP, e discharge, e referrals, e prescription service, Health Quality Measures, PMS certification

Hoping that any information system that is used for electronic claiming or access to public funds for provider payment (directly or indirectly) will need to be certified by July 2014.

Andrew outlined the progress on the development of prescribing module standards (for primary care prescribing systems) and the considerations that were involved.

So far work has been on the building blocks for improving prescribing quality e.g. NZULM, NZMF, e prescription service, review of PMS functionality and HISO standards for e pharmacy (by Q4 2012).

Patients First would prefer a prescribing system standard that can be used for all systems rather than one system.

Next steps are to consider the prescribing qualitative functional considerations for PMS review and where any prescribing module will sit (i.e. who is accountable, who is auctioning it and by when)

The group members offered support as an advisory group.

Discussion on who should do the work and

Bev and Mary-Anne keen to be involved when consideration of the functional requirements is undertaken for GP systems

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who should action the standards? Patients First keen to do the work and

have the necessary contacts and would like the MSEAG to act as an advisory group.

4. a. eMedicines management, patient banner requirements (Paula Campbell)

Paper submitted discussed. The patient banner will be standardised so

that the same information is always in the same place on the screen.

Primary care also have a patient banner and it was agreed would need to be included in the standards and then in certification.

The patient banner standard was approved

b. eMedicines management nurse administration enhancement (Paula Campbell)

Paper submitted discussed. Support for a 2 step process for

administration was given by nursing members for a variety of reasons e.g. if an injection requires reconstitution or when a patient vomits and cannot immediately be given following withdrawal from the storage location. In either example, within the ePA system, the medicine would currently be signed as administered when the medicine was withdrawn from storage but in fact administration would not occur immediately.

The group supported the need for a two-step process but did not support the inclusion of batch retrieval in the current document. Felt that batch retrieval was not ideal in terms of patient safety and should not be encouraged.

Re-word document to include two step documentation with no mention of batch retrieval (Paula)

5. Patient pamphlet final and distribution plan

Final version of the pamphlet was circulated.

Beryl commented that a larger font would have been more appropriate

PHARMAC had generously agreed to store the pamphlets and distribute when ordered.

The order form and initial distribution had not been organised yet.

Organise distribution (Beth/Emma)

6. Future work streams – health literacy/ consumer engagement

Three questions were posed in the background paper and these formed the basis for discussion:o How can the medication safety elements of the Commission’s Partners

in Care high level framework best be achieved?

o Amongst competing priorities consider where the initial effort should be directed?

o Are there other work streams that should be considered in the future?

The background to the Commission’s health literacy work stream was outlined.

The Commission Board had asked the NZGG to identify what work was on going in NZ in the field of medication safety and health literacy.

It was agreed that efforts needed to be

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focussed on consumers but also needed to include health professionals.

The NPS MedWise system in Australia needed to be developed in our system i.e. a range of resources were available; leaflets, TV/radio, online and one to one education.

Important not to forget disability groups. Discussion about whether the focus should

be on both high risk medicines or high risk situations (e.g. aged residential care).

Workbase have looked at different levels of health literacy based on manufacturing in South Auckland.

Agreed that consumers only intersect with health professionals occasionally and that there is a need for greater self-management.

What level should we operate on – a strategic or an operational level?

There is a need to partner with people that aren’t represented at this meeting and it is necessary to meet with these groups prior to deciding a strategy.

Need to prioritise and flag people who may have problem understanding.

There was discussion about whether our role should be to set standards about what is expected for health literacy and to advertise NZ initiatives.

The Australian Consumer Forum produces information leaflets and work to raise health literacy.

Consumer error reporting systems in the US and Canada are available and promote health literacy

One good step would be creating a place where people can access good information and messages on medication safety e.g. do not give your medicines to friends.

What is the aim of any health literacy work – that consumers understand the system and the medicines they take.

Medsafe had developed a 3 year communication strategy that considered internal, external (i.e. with other agencies) and consumer engagement.

7. Measurement and evaluation

David Moore, Preston Davis and Joanna Smith from Sapere presented a draft of the measurement and evaluation framework

The focus is on measuring for patient safety, cost effectiveness and system implementation.

Had looked at some robust and targetable measures which have prohibitively expensive methodologies. Discussion about data collection being difficult and costly.

Suggested some measures for all areas i.e. eMR and ePA, some ePA only, some eMR only

Feedback any further comments on the measuring and evaluation framework to Beth/Nirasha (All)

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Concerned about measuring a baseline for ADE following visit to Taranaki i.e. how to monetise ADEs to be able to evaluate cost/benefit, measure and monetise productlivity impacts, finding suitable indicators, resourcing for data extraction.

Who owns the data when it has been collected – discussion based on DHBs needing to be the owners because of publishing the results, certainly not clear who was going to own the data at this point in time.

Sapere will publish a report which will belong to the Commission but unclear who will own the data.

Productivity gains not currently being measured in any detail although the NZIER cost benefit analysis was based on productivity gains.

Taranaki are doing some time and motion studies in their work. Will this data be used?

It was mentioned that it may be 12 – 36 months before the full benefits from changing a system are fully realised so measuring during and immediately after implementation may not identify the benefits.

The global trigger tool (GTT) indicator work in NZ doesn’t match the US GTT system e.g. do ADEs/ 100 admissions rather than ADEs/1000 admissions.

Harm prevention has driven most of the initiatives so far but productivity is driving go for gold.

Overseas evaluation looks at decreasing errors not patient harm.

Looking at errors – only a small % cause harm so cost effectiveness not good.

It is recognised that only about 10% of errors are reported and the level of harm caused cannot always be determined.

How can patient harm be measured:1. ADE trigger tool currently do 20/month

but to measure statistically need to do 1000/month, includes both preventable and non-preventable harm and doesn’t identify omission errors

2. ADE trigger tool results can’t be used to compare DHBs

3. GTT work is resource intensive and and difficult to generate information

Could the culture i.e frontline practitioners’ knowledge of medication safety be looked at?

It was acknowledged that the baseline for ADEs should have been measured at the start of the project i.e. before pilots started.

Taranaki have done some measuring but nothing repetitively except the eMR reports.

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Is the proposed evaluation considering whether ePA and eMR by 2014 is a sensible target or not - it will not totally answer the question but will provide some information.

Intuitively know that introduction of eMR and ePA is good sense but evaluation may not show this.

The anticipated productivity gains may not be realised, this is the experience in other projects.

One way of looking at the evaluation is to determine:1. Should we be going for gold2. How much money will we save3. How should it be rolled out

Consider implementation lessons not evaluation measures.

8. ACC update Sreekanth presented the latest ACC treatment injury report.

The latest case study on paracetamol and the other case studies released by ACC were discussed, a case study is published every month.

Each case study published reflects information from a range of cases rather than a single case.

There was a discussion about how the case studies are disseminated because they were a useful resource but not all members were aware of them.

ACC are developing a consumer website that will contain consumer related information on treatment injury.

Useful to link from HQSC website to both the paracetamol and insulin case studies (Beth)

ACC have data on incidents which may help inform the insulin project (Beth)

9 NZPhVC update The NZPhVC presented the final report on MERP.

The piloted MERP system yielded useful and timely data about the types and causes of med errors.

The proposed next phase involves roll out of the individual reporting component to all community pharmacists and general practitioners. Funding opportunities are currently being explored.

In the future, the MERP could be adapted to develop a parallel consumer reporting programme and could also be extended to residential care and to secondary care which would facilitate the collection and analysis of standardised data on medication errors at a national level.

Members commented that there is a need to share learning from primary care incidents across secondary care.

NMDHB are able to report primary/secondary transfer of care incidents on the Nelson pathways site.

The biggest issue the confidence to report incidents.

Dwayne shared a report on medication incidents across bupa’s aged residential

Inform Commission of MSEAG support for funding (Beth)

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care facilities which actively encourage and support incident reporting; 5% related to prescribing 79% administration and 16% dispensing.

The MSEAG members agreed that MERP was a necessary service that was not duplicated in the sector and would support the Centre’s proposal to the Commission for funding.

10. NZ Medicines Formulary (NZMF)

David Woods provided a demonstration of the NZMF.

There are currently 150 monographs that need to be signed off by July 19 for the launch on July 23.

There was a discussion on medicines that were or were not included in the NZULM and would therefore be included or not in the NZMF e.g. some Section 29 medicines would be in NZMF.

The HQSC alerts are linked to the NZMF under the appropriate monograph.

There was a discussion on the launch and how the information was being disseminated to both DHBs and the public.

Integration into systems e.g. PMS would happen later.

It was suggested that it would be good to add health literacy information to the NZMF.

11. National Prescribing Symposium Australia

The paper provided information on the symposium and Nirasha commented on the quality and usefulness of the sessions

Technical Agenda

12. a. Labelling and packaging – Tall Man lettering

The Australian Commission have given permission for the standard and list of medicines to be used as a basis for the NZ work

It is planned that a team will review the list at the end of June

Organise review of Tall Man list (Emma)

12. b. Labelling and packaging – NZULM synonyms/ alternative names

The list of problem synonyms mentioned in the communication from CMDHB had now been updated in the NZULM

13. Serious Event (SSE) Learning Report

All DHBs had received a learning report on an SSE highlighting the risks associated with sharing protocols between DHBs and the use of abbreviations.

The inclusion of the updated error prone abbreviations poster in Medication Safety Watch was timely.

14. Early warning signal

It was agreed that suggested actions should be included on the early warning

Update early warning signal appropriately

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signal. (Beth)15. Insulin a. Risk of

confusion because of similar names

The risk of confusion because of the similar names used for insulin products has been highlighted by CCDHB e.g. Humalog, Humulin, Humalog Mix.

A letter, from Paul Drury, chair NZSSD has been received supporting the CDHB proposal that there was a need for action on the safe use of insulin.

The insulin project proposal tabled at the February meeting would consider this aspect of safe use of insulin as well.

It was important to meet with the MoH chronic care conditions work stream before the project proceeded to prevent duplication of work.

Ascertain what if anything is happening internationally about insulin names through IMSN network (Nirasha)

Write to worldwide CE’s of Eli Lilly and Novo Nordisk highlighting the issue (Beth)

Insulin b. Project proposal for Partners in care work stream

Project proposal included for information. Aims to identify what information resources

adult consumers need around the safe use of insulin using the partners in care model t

The information gained would also inform the wider insulin project.

16. Dabigatran The Boehringer Ingelheim representative had questioned the wording in the dabigatran alert stating that there was an increased risk of bleeding.

The group believed this was a valid comment because dabigatran was an anticoagulant and the same would be said about any anticoagulant.

Reply to Boehringer regarding their concerns (Beth)

17. Heparin action plans

Completed action plans have been received from 12 DHBs.

Six DHBs are working to complete the actions.

One DHB has had resource issues and has been unable to initiate the actions but these have now been resolved.

Two DHBs were unaware of where the alert had been sent for action but had started work on the actions.

Follow up with outstanding DHB (Beth)

18. NZPhVC error reporting project – codeine linctus

PHARMAC were sending the prescribing details to help identify in which areas codeine linctus was prescribed.

There had been no information supplied by Starship but Rob understood that it was prescribed by the ENT department for pain.

To review the prescribing information (Beth)

Check indication at Starship (Rob)

19. Paediatric Weight based dosing alert

This had not been released yet and delaying release until September because of the winter period was suggested.

Release alert in September (Beth)

20. Dosing in renal impairment alert

After some debate it was agreed that this alert did not fit into the group’s current focus and that it should not be issued .

21. Other alerts in development

No discussion required.

22. Paracetamol induced liver damage

The articles for Kaitiaki and bpac had been submitted.

The article for Pharmacy Today is in progress.

Complete Pharmacy Today article (Beth)

23. NHI allergy alert The alerts were not visible in primary care. Update from

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issues MoH/NHITB on the NHI system upgrade (Beth)

24 Date for October meeting and proposed July meeting

Send out a list of proposed dates and await response.

Send out list of dates (Beth)

Any other business

Rob raised the issue of medicine names changing from British Approved Names (BANs) to recommended international non-propriety names (rINN).

Medsafe now required rINN to be used on all new listings.

The NZULM was able to continue listing both the BAN & the rINN name and it was agreed that this would help.

Agreed to provide information in the next edition of Medication Safety Watch.

Providing information in NZ Doctor & Pharmacy Today would help inform the sector.

Put information on BANs to rINN in next edition of Medwatch (Nirasha)

Articles in Pharmacy Today and NZ Doctor (Nirasha)

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