The West Australian Point Prevalence Survey 2014: Medication Safety
The Western Australia Point Prevalence Survey (WAPPS) State-wide survey conducted in May 2014, co-ordinated by the Quality Improvement and Change Management Unit, Patient Safety and Clinical Quality Division. 14 metropolitan and 6 country public hospitals 40 beds Examined adherence to 6 safety and quality topic areas based on the National Safety and Quality Health Service (NSQHS) standards, including medication safety. Survey data was linked to hospital morbidity data prior to detailed statistical analysis.
Analysis of Data from the WA Point Prevalence Survey (WAPPS) 2014 Prepared by the Collaborative for Healthcare Analysis and Statistical Modelling (CHASM) Iteration 5 29 th May 2015
WAPPS MODULE F : Medication Safety - survey questions focused on Medication Reconciliation process Medication reconciliation process involves: 1. Best Possible Medication History (BPMH) 2. Confirm with two sources 3. Reconcile differences identified
The Western Australia Point Prevalence Survey (WAPPS) Exclusions dialysis patients psychiatric patients (on a mental health ward) unqualified newborns hospital in the home clients day surgery patients day procedure patients patients admitted less than 24 hours Teams of two surveyors: Hospital clinical team member + survey volunteer Direct patient contact, data collection Examining the medical record Education Session 4 hour sessions on NSQHC standards and survey tool. What happened with the data? Raw data provided to hospitals Data linkage and statistical analysis by UWA
Cohort
Percentage of Patients with a Medication History Documented for Current Admission Univariable analysis: percentage of patients in each WA hospital examined who had their medication history documented for the current admission.
Percentage of Patients with a Medication History Documented for Current Admission Patient Characteristic (risk factor) Reference Group Adjusted OR (LCL, UCL) Estimated change in the number of patients with the outcome (LCL, UCL) Estimated annual change in the number of patients with the outcome* (LCL, UCL)** Estimated annual change as a percentage of the estimated annual number of patients with the risk factor + (LCL, UCL) Adult Paediatric LOS 0-5 days Birthing mothers Older adult Older adult LOS 6+ days - 0.473 (0.343, 0.653) 0.133 (0.066, 0.268) 0.484 (0.356, 0.658) 0.251 (0.157, 0.402) 74 (42, 105) 26 (17, 35) 92 (55, 129) 40 (26, 53) Multi-variable logistic model of the probability of a patient having their medication history documented during the current admission 2502 (1399, 3548) 1055 (681, 1420) 6141 (3631, 8559) 3046 (2024, 4041) 8 (4, 11) 20 (13, 27) 7 (4, 10) 26 (17, 35)
Was a Medication History Documented? Multivariable logistic model of the probability of a patient having their medication history documented during the current admission
Was a Medication History Documented? Higher likelihood of paediatric patients being documented at PMH compared to paediatric patients at other hospitals (OR 3.9 (1.7-8.9)). Higher likelihood of birthing mothers being documented at KEMH compared to birthing mothers at other hospitals (OR 4.5 (2.0-10.3)).
Medication History Documentation In 2010 the Pharmaceutical Review Policy follow-up audit was undertaken. A medication history was documented for 77% (2010) of all patients audited (WAPPS: 88% in 2014), with only 50% of patients at regional sites having evidence of a medication history documented. This demonstrates improvement in this process for medication reconciliation (11.2%, 95% CI: 8.5% to 13.8%); p-value < 0.0001) on admission across WA Health, especially for regional patients.
Confirmation of medication history with a second source improves the accuracy and completeness of the medicines list. Documentation of sources used to confirm the medication history is important as it provides a reference of the information obtained, as well as minimising the risk of using a source more than once. The WA MMP provides a consistent approach to documenting this information. Documentation of the medication history on the NIMC does not adequately capture the confirmation of the medication history with another source.
Was the Medication History Confirmed By At Least Two Sources? Univariable analysis: percentage of patients in each WA hospital examined who had their medication history confirmed by at least two sources.
Was the Medication History Confirmed By At Least Two Sources? Patient Characteristic (risk factor) Reference Group Adjusted OR (LCL, UCL) Estimated change in the number of patients with the outcome (LCL, UCL) Estimated annual change in the number of patients with the outcome* (LCL, UCL)** Estimated annual change as a percentage of the estimated annual number of patients with the risk factor + (LCL, UCL) Paediatric Older adult 0.291 (0.093, 0.905) Adult LOS 0-5 days Older adult LOS 6+ days 0.447 (0.354, 0.565) 0.672 (0.539, 0.838) 14 (2, 24) 101 (70, 128) 66 (31, 104) 547 (79, 948) 3402 (2353, 4307) 4416 (2077, 6906) 28 (4, 48) 16 (11, 20) 8 (4, 12) Multi-variable logistic model of the probability of a patient having at least two sources of confirmation of their medication history
Was the Medication History Confirmed By At Least Two Sources? Multivariable logistic model of the probability of a patient having at least two sources of confirmation for their medication history
Where was the medication history documented? 5 possible options for survey question: WA Medication History and Management Plan ( WA MMP) National Inpatient Medication Chart (NIMC) Medical Record (MR) Paediatric Inpatient Medication Chart (PIMC) Other
Where was the medication history documented?
Was The Medication History Reconciled? Identified Medication Management Issues Reconciled with NIMC column
Was The Medication History Reconciled? Univariable analysis: Percentage of patients with a WA MMP who had their medication history reconciled.
Was The Medication History Reconciled? Multivariable logistic model of the probability of a patient with a WA MMP having their medication history reconciled Patient Characteristic (risk factor) Reference Group Adjusted OR (LCL, UCL) Estimated change in the number of patients with the outcome (LCL, UCL) Estimated annual change in the number of patients with the outcome* (LCL, UCL)** Estimated annual change as a percentage of the estimated annual number of patients with the risk factor + (LCL, UCL) Adult Older adult 0.510 (0.380, 0.683) 45 (25, 64) 1517 (837, 2155) 12 (7, 17) 0 prior admissions 1+ prior admissions 0.402 (0.253, 0.639) 17 (8, 26) 487 (222, 759) 19 (8, 29)
Summary Report Recommendations 2014 Health Services/Sites: 1. Adopt the WA Medication History and Management Plan 2. Sites with paediatric patients should review processes for documentation of medication history. 3. Sites with mothers being admitted for childbirth should review processes for documentation of medication history and clinical handover of this information at point of admission to hospital. 4. Review process of medication reconciliation to ensure that two sources of confirmation are used (unless deemed unnecessary by the clinician conducting the medication reconciliation) and sources are documented on the WA Medication History and Management Plan. (WA MMP). State-wide: A method of risk assessment should be developed to assist with prioritising the medication reconciliation service to those patients deemed at higher risk of experiencing medication-related adverse events. This would assist sites impacted by resource limitations.
Acknowledgements: WA Data Linkage Unit WAPPS Project Team WAPPS Steering Group Quality Improvement and Change Management (QICM) Unit Matthew Tuson Kerry Fitzsimons (QICM Unit) Berwin Turlach Alistair Vickery