Medication issues in

Australia
Jane Booth
June 2014

A typical Australian hospital

3 facilities - 1 health service

Royal Talbot Rehabilitation
Centre - founded 1907

Austin Hospital
- founded 1880

Heidelberg Repatriation
Hospital - founded 1941

Catchment area
Primary catchment area
Banyule and Darebin
Population >260,000 people
(expected to grow by 2.1% by
2016)
Culturally diverse, of Darebin
residents born in a non-English
speaking country
Significant Aboriginal
community
Areas of social disadvantage

Extended catchment area

Population 1.2 million people

An overview of Austin Health

1.

980 beds across the 3 campuses (including day beds)

2.

8,000 staff

3.

91,661 inpatient admissions and 176,426 outpatient attendances in 201213

4.

71,391 ED presentations in 2012-13 (4.8% increase from 2011-12)

5.

Statewide services are based at Austin Health:

Victorian Spinal Cord Service

Victorian Respiratory Support Services

Victorian Liver Transplant Unit
Acquired Brain Injury Unit/Brain Disorders Unit (Royal Talbot Rehabilitation)
Child Mental Health Inpatient Unit
Victorian Toxicology Service & Poisons Centre
Psychological Trauma Recovery Service (including Veterans Psychiatry)

An overview of Austin Health

6. Other specialty units

Psychiatry (inc. Child, Adolescent & Adult inpatient units, Secure Extended
Care Unit, Parent & Infant Service, Body Image/Eating Disorders Service,
Psychological Trauma Recovery Service/Veterans Psychiatry, Drug
Dependency Clinic)
Emergency Department
Paediatrics and Paediatric Surgery
Intensive Care Unit, Anaesthetics & Pain Services
General Medicine
Aged Care
Rehabilitation (including Brain Disorders, Acute Brain Injury, Amputee)
Spinal (including Spinal Surgery)
Gastroenterology, Liver Transplant Unit
Infectious Diseases

An overview of Austin Health

6. Other specialty units

Renal (including transplant)

Oncology, Haematology, Radiation Oncology, Palliative Care
Respiratory (inc VRSS), Sleep Laboratory and Thoracic Surgery
Cardiology and Cardiac Surgery
Neurology, Acute Stroke Unit and Neurosurgery
Endocrinology
Rheumatology
Vascular Surgery
Toxicology
Oral and Maxillofacial Surgery, Ear Nose and Throat Surgery, Head and Neck
Surgery, Ophthalmology
Orthopaedic Surgery
Various other surgical units

Pharmacy Department Statistics

1. Pharmacists

80 Pharmacists (approx. 60 FTE) work in the Pharmacy Department

4.5 FTE (Pharmacists & Toxicologists) work in Poisons Information
3 FTE Pharmacists work in Clinical Informatics
2 Pharmacists work for chronic disease management (Outreach)
1 FTE Pharmacist works in nuclear medicine (Radiopharmacy)
0.5 FTE Infectious Diseases consultant for Antimicrobial Stewardship

2. Technicians and support staff

23 Pharmacy Technicians
10 Pharmacy Store staff

3. Intern pharmacists

7 Intern Pharmacists

Pharmacy Department Statistics

The Pharmacy Department manages a 42 million dollar of drug
expenditure a year.
On an average day, we:
dispense 220 outpatient prescriptions
dispense 600 discharge prescriptions
dispense 80 methadone doses
provide 540 non-imprest inpatient items
prepare 45 sterile and non-sterile preparations
compound 70 cytotoxic sterile preparations
process 20 clinical trials

66% of pharmacists have a higher qualification, i.e. Graduate Certificate

of Pharmacy or above.

28% of pharmacists have a Masters or Doctorate.

An overview of Austin Health

Australias first small bowel transplant in 2010.
Small bowel (intestinal transplant). For this patient,
the liver, pancreas, bile ducts, duodenum & small intestine were transplanted, patient retained
stomach and stoma site.
Austin Health is now the Australian referral hospital
for other potential small bowel transplant candidates
e.g. patients on long term home TPN

Olivia Newton-John Cancer &

Wellness Centre
Outpatient services, day oncology and specialist clinics opened in
December 2012 and the inpatient wards opened in July 2013.
The Centre offers care for all aspects of cancer treatment including:
Outpatient/Specialist Clinics
Day Oncology & Apheresis
Radiation Oncology
Palliative Care
Clinical Genetics Service

Wellness is central to the Centre's philosophy, expressed through the

evidence-based complementary therapies offered in the Wellness Centre
Austin Health's Medical Oncology Unit is run jointly with leading international
cancer research organisation the Ludwig Institute for Cancer Research, allowing
patients to benefit quickly from the latest scientific discoveries.

A typical day for a ward

pharmacist

Hospital Pharmacy Practice in Australia

What do Austin ward pharmacists do in

a day?
1.

Identify new patients and order any non-imprest stock

Will be dispensed in one of the Satellite Pharmacies

2.

Find out who is going home and begin reviewing discharge scripts

Might be dispensed by the Satellite Pharmacies

Supply medication list, warfarin discharge plan, RACF chart prn

3.

Take discharge medications back to the ward and provide bedside counselling

4.

Admit new patients

Medication Reconciliation

5.

Review all patients drug charts

6.

Respond to queries / requests etc

7.

Attend ward handover with allied health and discharge coordinators

8.

Perhaps attend ward rounds

Current issues of medicines

use in Australia

Current medication issues in Australia

Australian Commission for Quality and Safety in Healthcare:
National Standards Accreditation
National Inpatient Medication Chart
Medication reconciliation
High Risk Medications
Naming, labelling and packaging of medicines
VTE Prevention
Electronic prescribing / eHealth

Current medication issues in Australia

Australian Commission for Quality and Safety in Healthcare:
National Standards Accreditation
National Inpatient Medication Chart
Medication reconciliation
High Risk Medications
Naming, labelling and packaging of medicines
VTE Prevention
Electronic prescribing / eHealth

Current medication issues in Australia

Australian Commission for Quality and Safety in Healthcare:
National Standards Accreditation
National Inpatient Medication Chart
Medication reconciliation
High Risk Medications
Naming, labelling and packaging of medicines
VTE Prevention
Electronic prescribing / eHealth

Current medication issues in Australia

Australian Commission for Quality and Safety in Healthcare:
National Standards Accreditation
National Inpatient Medication Chart
Medication reconciliation
High Risk Medications
Naming, labeling and packaging of medicines
VTE Prevention
Electronic prescribing / eHealth

High risk medicines

Anti-infectives
P
Potassium and other electrolytes
IInsulin
N
Narcotics
C
Chemotherapeutic agents
H
Heparin and other anticoagulants
Systems

High risk medicines

Systems:
Infusion pumps
Patient controlled analgesia
Liquid medicines and wrong route errors
Patient handover

Current medication issues in Australia

Australian Commission for Quality and Safety in Healthcare:
National Standards Accreditation
National Inpatient Medication Chart
Medication reconciliation
High Risk Medications
Naming, labeling and packaging of medicines
VTE Prevention
Electronic prescribing / eHealth

Naming, labelling and packaging of

medicines
Tall Man Lettering:
cefEPIME
cefOTAXIME
cefOXITIN
cefTAZIDIME
cefTRIAXONE
cefALOTIN
cephaLEXin
cephaZOLin

Current medication issues in Australia

Australian Commission for Quality and Safety in Healthcare:
National Standards Accreditation
National Inpatient Medication Chart
Medication reconciliation
High Risk Medications
Naming, labeling and packaging of medicines
VTE Prevention
Electronic prescribing / eHealth

The National Healthcare

Standards

Background National Standards

From January 1st 2013, all Australian
health services will be accredited against
the new national standards (10 in total)
Against each standard:
core (critical) actions
developmental (aspirational) actions

Total of 256 actions across the ten

national standards
Assessment based on a three point
rating scale (not met, satisfactorily met,
met with merit)

Standard

Core Actions

Developmental Actions

Governance for Safety and Quality in Health Service

Organisations
Partnering with Consumers

44

11

Preventing and Controlling Healthcare Associated Infections

39

Medication Safety

31

Patient Identification and Procedure Matching

Clinical Handover

Blood and Blood Products

20

Preventing and Managing Pressure Injuries

20

Recognising and responding to Clinical Deterioration in Acute

Health Care
Preventing Falls and Harm from Falls

15

18

209

47

Structure of Each Standard

Requirement for each standard:
Do we have a governance structure in place?
Do staff access policies and procedures?
and are these compliant with best practice?
Do we monitor when things go wrong?
Do staff have access to tools and processes?
and are these compliant with best practice?
Do we provide education and training for our staff?
Do we audit what we are doing?
Do we appropriately involve consumers?

The intention of this (Medication

Safety) Standard is to ensure
competent clinicians safely prescribe,
dispense and administer appropriate
medicines to informed patients and
carers

Standard 4 Medication Safety

Governance and systems for medication safety
Health service organisations have mechanisms for the safe prescribing, dispensing,
supplying, administering, storing, manufacturing, compounding and monitoring of the
effects of medicines.

Documentation of patient information

The clinical workforce accurately records a patients medication history and this history
is available throughout the episode of care.

Medication management processes

The clinical workforce is supported for the prescribing, dispensing, administering, storing,
manufacturing, compounding and monitoring of medicines.

Continuity of medication management

The clinician provides a complete list of a patients medicines to the receiving clinician and
patient when handing over care or changing medicines.

Communicating with patients and carers

The clinical workforce informs patients about their options, risks and responsibilities for
an agreed medication management plan.

Electronic prescribing

Electronic Patient Record

Since 2011 Austin Health has implemented a clinical system for patient care (Cerner)
Inpatient Medication ordering and administration (MAR)
Ordering of Prescriptions
Ordering of Pathology and Radiology
Electronic recording of specimen collection
Electronic Discharge Summary
Fluid Balance Chart
Allied Health Referrals
Patient care orders
Results reporting and acknowledgement
Documentation of some clinical information e.g. allergies, diagnoses, alerts, past history
and procedures are recorded on Cerner

Improvements for pharmacists

Each pharmacist has a personal laptop to carry out
their daily functions in the system
PharmNet software:
Includes a monitor screen that shows the
pharmacist all new and modified orders for
patients in their specific ward(s)
Enables review of medication charts and
generating dispensing labels remotely
Integrates with the dispensing system to prevent
dual data entry
Streamlined medication supply to the ward as system
knows when resupply of medications due

No more looking around for missing drug charts!

1. National Medication Chart vs. Power Chart

National Medication Chart
All orders are to be written legibly in ink
No erasers or whiteout can be used. Must be
rewritten if changes occur

Cerner PowerChart
All orders placed electronically. 100% of orders are
legible
All changes tracked transparently in the system.
Certain fields locked down on Modify

Adherence to national standards around

terminology

Terminology hard-coded (via code sets). Avoids

unsafe abbreviations and symbols

Essential details such as date of order, generic

Order Entry Format will ensure fields are present in
medication name, frequency and signature must be
every order which must be accompanied by an
present
electronic signature
Accurately portrays medication administration
Task clearly states when medication to be given as
requirements
well as contains last dose information.
Tasks become RED when overdue
Patient identification details present on ALL charts Details present at all times in Cerner in the banner
bar
If more than one chart exists, it should be clearly
numbered

Only one chart exists for a patient in the same

location

1. National Medication Chart vs. Power Chart

Electronic medication management system

Drug chart does not run out of time or space

Decision support through alerts
Closed-loop medication management
Pre-built order sentences minimise risk of order entry errors
Ability to enforce prescribing guidelines and policies

1. National Medication Chart vs. Power Chart

Pre-Built Order Sentences: cephalexin

1. National Medication Chart vs. Power Chart

Medication administrations instructions: Ciprofloxacin

2. Antibiotic Stewardship
To promote appropriate and proper prescribing of
antimicrobials
Antimicrobial Stewardship programs aim to reduce
chance of antimicrobial resistance, toxicity and
unnecessary costs
Multiple methods employed in the eMM context:
Electronic Approval System (*external to Cerner)
Specialised Care Sets and Order sentences including time
offsets and drug level reminder tasks
Alerts
Reports

2. Antibiotic Stewardship Care Sets

Care Sets contain the ability to include prescribing
guidance and information
Ability to combine medications, pathology and
radiology orders in one ordering window
Ability to incorporate time off-sets on orders to
facilitate drug level monitoring

2. Antibiotic Stewardship Care Sets

Vancomycin: Initiation Care Sets

2. Antibiotic Stewardship Care Sets

2. Antibiotic Stewardship Alerts

Austin Healths Good Antimicrobial Prescribing
Practice (GAPP) policy required custom build in to
Cerner.
Currently using an online approval system (IDEA3S) to
generate approval numbers based on selection criteria
On paper
Approval number is written on the drug chart
Required before administration but not always followed

In Cerner
Creative use of Discern Alert
Cannot proceed with order unless approval number is
documented in appropriate field

2. Antibiotic Stewardship Alerts

3. Venous Thromboembolism Prophylaxis

Venous thromboembolism remains a major cause of
morbidity and mortality in hospitalised patients
National guidelines and recommendations in place to
ensure appropriate measures taken to reduce this risk
Locally developed policy states all acute inpatient
admissions should have a VTE risk assessment within 24
hours of admission and documented in the medical
record
Previous practice: Dedicated section on paper drug
chart for VTE Prophylaxis prescribing. VTE Risk
Assessment guideline printed on every paper drug
chart

3. Venous Thromboembolism Prophylaxis

3. Venous Thromboembolism Prophylaxis

Power Form for prescribers to document VTE Risk assessment

3. Venous Thromboembolism Prophylaxis

3. Venous Thromboembolism Prophylaxis

Power Plan to guide ordering of medications

3. Venous Thromboembolism Prophylaxis

Alert: High Risk VTE documented but no VTE Prophylaxis

4. Allergy Documentation
Having allergy information readily available reduces the risk of
patients having an adverse event
Should be available to all those who prescribe, dispense and
administer medications
Local policy states all patients should have their allergy recorded
and all clinicians are responsible
Electronic medication management systems can warn prescribers
before an order is placed through allergy interaction checking (as
well as drug interactions)

4. Allergy Documentation

4. Allergy Documentation

4. Allergy Documentation
Austin Health - Allergy Audit
% Patients with Allergies Recorded
100,00%
99,00%

98,26%

98,00%
97,04%
97,00%
96,00%

97,44%

97,33%

97,83%
97,19%

97,30%

97,08%

96,80%

96,84%

Feb

Mar

96,28%

96,51%

95,57%

95,00%
94,00%
93,00%
92,00%
91,00%
90,00%
Apr

May

Jun

Jul

Aug
2013

Sep

Oct

Nov

Dec

Jan

2014

Apr

4. Penicillin Allergy Alert Audit

Total number of alerts between January 2013 and March 2013 = 324
- 147 instances resulted in a penicillin not being ordered
- 177 instances the alert was overridden and penicillin prescribed
177
alerts
88
alerts
46
alerts
34
alerts
10
alerts

7 meropenem allergies
82 cephalosporin allergies
42 cases of documentation OK to proceed
12 allergies of minor significance (e.g. nausea or
diarrhoea)
24 orders cancelled (i.e. not administered)
Need further investigation

4. Penicillin Allergy Alert Audit

10 alerts that needed further investigation to explain why a
penicillin was ordered for these patients
Out of the 10 alerts this affected 9 patients
8 patients received a penicillin without clear documentation
1 patient unable to ascertain if received a penicillin

No evidence of any adverse drug reactions documented in these

cases

4. Penicillin Allergy Alert Audit

Unfortunately no baseline data for comparison
45% of instances the alert stopped a penicillin being prescribed
147 out of 324 alerts

When excluding instances where it was appropriate to proceed

with penicillin treatment despite the alert
81% of instances the alert stopped a penicillin being prescribed
147/181 alerts

Moving forward
The future: enhancing data capture and interpretation
capabilities
The more information we can get in the more powerful
reporting and auditing becomes

Potential for powerful audits:

Actual Administration Times vs. Scheduled Administration
Times

Particularly interested in antibiotics

Number of missed doses

Patients who have received more than 4 grams of paracetamol
High Risk Drug audits

Acknowledgements
Alana Meaklim
Anne McGrath
Adrian Lio