Report from the Medication Safety Self Assessment (MSSA)

Report from the Medication Safety Self Assessment (MSSA) NSW PUBLIC HOSPITALS Feb 2007 - Nov 2007

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Report from the Medication Safety Self Assessment (MSSA) NSW PUBLIC HOSPITALS 3

Clinical Excellence Commission (CEC), NSW Therapeutic Advisory Group (NSW TAG), 2008 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the CEC. Requests and enquiries concerning reproduction and rights should be directed to the Director, Corporate Services, GPO Box 1614, Sydney NSW 2001. This publication is part of the CEC s Medication Safety Self Assessment Series. A complete list of CEC publications is available from the Director, Corporate Services (address above) or via the CEC s web site www.cec.health.nsw.gov.au. Suggested citation Clinical Excellence Commission (CEC), NSW Therapeutic Advisory Group (NSW TAG) 2008. Report from the Medication Safety Self Assessment (MSSA) New South Wales Public Hospitals February 2007 November 2007. Sydney: CEC Clinical Excellence Commission Board Chair: Prof Bruce Barraclough, AO Chief Executive Officer: Prof Clifford F Hughes, AO Acknowledgements Review of MSSA data was undertaken by Dr Peter Kennedy (Deputy CEO, Clinical Excellence Commission); Daniel Lalor (QUM Pharmacist, SSWAHS); Jocelyn Lowinger (Project Officer NSW TAG); Maria Kelly (Executive Officer, NSW TAG); Penny Thornton (Pharmacy Services Manager, The Children s Hospital Westmead); Rosemary Burke (Director of Pharmacy, Concord Repatriation General Hospital); Melita Van De Vreede (QUM Pharmacist, The Alfred Hospital, Bayside Health); Kai Zhang (Senior Analyst, Patient Safety, CEC); Bernadette King (Project Manager, Quality Systems Assessment, CEC) Enquiries Any enquiries about this publication, or comments, should be directed to: Dr. Peter Kennedy Deputy CEO Clinical Excellence Commission GPO Box 1614 Sydney NSW 2001 Phone: (02) 9382 7600 Email: peter.kennedy@cec.health.nsw.gov.au 4

Table of Contents Introduction... 7 Background on Phase 1... 8 MSSA Key Elements and Core Characteristics... 9 Scoring of the MSSA...10 Results from the NSW Medication Safety Self Assessment (MSSA)... 11 Key Elements:... 13 Core Characteristics... 14 Further Analysis of Poor Performing Core Characteristics... 15 Key Elements and Core Characteristics - Comparison of Metropolitan, Regional/Base and Rural/Remote Hospital Location... 17 Other Countries Results using MSSA... 19 Summary of Findings... 20 Recommendations... 20 Tables and Figures Table 1 MSSA 10 Key Elements... 9 Table 2 MSSA 20 Core Characteristics... 10 Table 3 MSSA Question Scoring Key... 10 Table 4 Number of Hospitals in Each Area Health Service (Public and Private) Which Completed the MSSA Assessment up to 31 November 2007... 11 Table 5 Aggregated Score for Each Area Health Service NSW... 12 Figure 1 NSW Aggregate Scores for 10 Key Elements... 13 Figure 2 NSW Aggregate Scores for Each Core Characteristic... 14 Figure 3 10 Key Elements, Comparison by Location... 17 Figure 4 Poor Performing Core Characteristics (1, 2, 4, 5, 14, 15) - Comparison by Location... 18 5

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Introduction Medication errors are often viewed as a symptom of system failure and can occur at any stage in the medication management pathway, most commonly in the prescribing, dispensing and administration of medications. A 2002 report from the Australian Council for Safety and Quality in Healthcare estimated that approximately 140,000 hospital admissions were associated with problems in the use of medicines, at an estimated cost of $380 million per year in public hospitals alone 1. In NSW, medication related incidents are the second leading cause of notifications to the Incident Information Management System (IIMS) 2. In 2005 the Clinical Excellence Commission (CEC), in collaboration with the NSW Therapeutic Advisory Group Inc. (NSW TAG), commenced the Performance Indicator and Medication Safety (PIMS) project. The aim was to develop a complementary set of tools that could be used to assist in improving medication safety systems and monitoring performance in Australian hospitals. The project was undertaken in two phases: phase 1: the adoption and field-testing of the US based Institute for Safe Medication Practices (ISMP) Medication Safety Self Assessment (MSSA) tool and associated Antithrombotic tool (MSSA_AT) and their implementation in NSW facilities phase 2: to revise and field-test the NSW TAG Manual of Indicators for Drug Use in Australian Hospitals and the NSW TAG Performance Indicators for Drug and Therapeutics Committees to produce an up to date set of Indicators for Quality Use of Medicines in Australian Hospitals Phase 1 of the PIMS project is almost complete with the MSSA tool fully implemented and undertaken by hospitals in NSW and other States in Australia; the MSSA_AT tool will be launched in the latter half of 2008. Phase 2 of the project has been completed, with the Indicators for Quality Use of Medicines in Australian Hospitals developed and available for use by hospitals in NSW. NSW TAG and the CEC will launch the indicators in 2008. 1 Australian Council of Safety and Quality in Health Care: Second National Report on Patient Safety: Improving Medication Safety. Commonwealth Department of Health, Canberra 2 Clinical Excellence Commission: Analysis of first Year of IIMS Data: Annual Report 2005-2006 7

Background on Phase 1 The ISMP is a US based not-for-profit organisation with over 20 years experience, devoted entirely to medication error prevention and safe medication use. The ISMP MSSA for hospitals was developed in the US and has been extensively used there and in Canada and is recognised as best practice. ISMP gave approval to the NSW TAG to adapt the ISMP MSSA for Hospitals, to make it suitable for use in Australian hospitals. Differences between the North American and Australian environments relating to hospital practice, drug distribution systems, legislation and product availability were considered in the adaptation of the ISMP MSSA for hospitals. For example, some questions were not applicable to Australian conditions and these were removed. Questions pertaining to systems not yet adopted by Australian hospitals, but seen as being feasible in the future (such as e-prescribing systems), were retained. The MSSA for Australian Hospitals is subject to copyright in the name of ISMP and has been adapted by NSW TAG with the permission of ISMP for use in the Australian health care environment. For more information on the work of ISMP go to http://www.ismp.org About the Medication Safety Self Assessment for Australian Hospitals The MSSA and MSSA_AT tools are diagnostic tools designed to allow self assessment of medication safety practices in hospitals and to heighten awareness of the characteristics of a safe medication system. The tools provide a structured framework for assessing current practice; can be used both for internal assessment and for benchmarking purposes. They allow hospitals to systematically identify gaps in practice and areas for improvement which can be measured over time. Benefits of Undertaking the MSSA To hospitals: identify opportunities for improvement in safe medication practices establish baseline measures and monitor progress over time facilitate multidisciplinary discussions and action to improve medication safety link local and state-wide medication safety programs and inform the progress of Statewide initiatives help with accreditation processes. At a Statewide level: allows benchmarking against peer hospitals provides Area Health Services, the NSW Health Department and the CEC with data to establish state priorities for medication safety improvements 8

MSSA Key Elements and Core Characteristics The MSSA is divided into ten key elements that have been shown to influence safe medication use significantly. 1. Patient information 2. Drug information 3. Communication of drug orders and other drug information 4. Drug labelling, packaging & nomenclature 5. Drug standardisation, storage & distribution 6. Medication delivery, device acquisition, use & monitoring 7. Environmental factors, workflow and staffing patterns 8. Staff competency & education 9. Patient Education 10. Quality processes & risk management Table 1 MSSA 10 Key Elements Each key element is defined by one or more core characteristic of a safe medication system (20 in total). These are: C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 C13 C14 Essential patient information is obtained, readily available in a useful form and considered when prescribing, dispensing and administering medication. Essential drug information is readily available in useful form and is considered when prescribing, dispensing, and administering medications. A controlled drug formulary system is established. Methods of communicating drug orders and other drug information are standardised and automated to minimise the risk of error. Strategies are undertaken to minimise errors with look and/or sound alike drugs. Readable labels that clearly identify drugs are on all drug containers and drugs remain labelled up to the point of actual drug administration. Doses and administration times are standardised whenever possible. Medications are provided to patient care units in a safe and secure manner and available for administration within a timeframe that meets essential patient needs. Unit-based ward or imprest stock is restricted. Hazardous chemicals are safely isolated from patients and not accessible in drug preparation areas. The potential for human error is mitigated through careful procurement, maintenance, use and standardisation of devices. Medications are prescribed, prepared, dispensed and administered in a physical environment that offers adequate space and lighting and allows clinicians to remain focused on medication use without distractions. The complement of qualified, well-rested clinicians matches the clinical workload without compromising patient safety. Clinicians receive sufficient orientation to medication use and undergo baseline and annual competency evaluation of knowledge and skills related to safe medication practices. 9

C15 C16 C17 C18 C19 C20 Clinicians involved in medication use are provided with ongoing education about medication error prevention and the safe use of drugs that have the greatest potential to cause harm if misused. Patients and/or their parents/carers are included as active partners in their care through education about their medications and ways to avert errors. A non-punitive, systems-based approach to error reduction is in place and supported by management and senior administration Clinicians are encouraged to detect and report errors; multidisciplinary teams regularly analyse errors that have occurred both inside and outside the organisation for the purpose of redesigning systems to best support safe clinician performance. Simple redundancies that support a system of independent double checks or an automated verification process are used for vulnerable parts of the medication system to detect and correct serious errors before they reach patients. Proven infection control practices are followed when storing, preparing and administering medications. Table 2 MSSA 20 Core Characteristics ISMP is not a standards setting organisation and the self assessment characteristics do not purport to represent a minimum standard of practice. Their value however, in reducing errors, is grounded in scientific research and expert analysis of medication errors and their causes. Scoring of the MSSA Each question is assigned a weight for the purpose of working out an absolute score for the assessment of each core characteristic, key element and the assessment as a whole. Each item in the self assessment has a maximum score that ranges from 4 to 16 depending on the impact and long-lasting effect of full implementation of each item on medication safety. Maximum scores for each question can only be achieved when items are fully implemented (score of E ). Score A B C D E Interpretation There has been no activity to implement this item, that is, this item has never been considered. This item has been formally discussed and considered, but it has not been implemented for any number of reasons eg. timing, viability This item has been partially implemented in some or all areas of the organisation. This item is fully implemented in some areas of the organisation. This item is fully implemented throughout the organisation. Table 3 MSSA Question Scoring Key The scoring is not the same for all characteristics because some identify situations representing a higher safety risk than others. Full implementation of some items provides a substantial reduction in risk so these items receive a higher potential score. The self assessment items with the highest weight are those that: Target the system, not the workforce Do not rely heavily upon human memory and vigilance 10

Demonstrate through scientific evidence that they are effective in reducing serious medication errors Solve several medication-error related problems at the same time Prevent errors with high-alert medications that have the greatest potential to cause patient harm Simplify complex, error-prone processes Safeguard high-risk patient populations Make healthcare practitioners less prone to error. 3 Results from the NSW Medication Safety Self Assessment (MSSA) From February to November 2007, 89 facilities (84 public, 5 private) in NSW completed the self assessment and entered their data via a password-protected website. Data from Multi Purpose Service (MPS) facilities are not included in this report because hospitals with no onsite pharmacy service score low in the MSSA. Inclusion of these results in the aggregate data could skew results. Those facilities are able to view their data and generate comparative reports from the database. Private hospital data will also be excluded from aggregate data in this report. Table 4 Number of hospitals (public) in each Area Health Service who completed the MSSA assessment up to 31 November 2007 AHS Location Metropolitan Regional/Base Rural/remote Total GSAHS 0 2 3 5 GWAHS 0 4 8 12 HNEAHS 1 9 14 24 NCAHS 0 6 15 21 NSCCAHS 10 0 0 10 JUSTICE HEALTH 1 0 0 1 SESIAHS 2 1 0 3 SSWAHS 5 1 0 6 SWAHS 1 0 1 2 NSW 20 23 41 84 3 Medication Safety Self Assessment (MSSA) for Australian Hospitals: CEC, NSWTAG 11

Table 5 Aggregated score for each Area Health Service NSW 12

Key Elements: The major areas of weakness from the NSW results include the Key Elements of: 1. Patient information 2. Drug information 3. Communication of drug orders and other drug information 4. Drug labelling & packaging 6. Medication device acquisition, use and monitoring 8. Staff competency and education. The Key Elements of relative strength identified include: 5. Drug standardisation, storage and distribution 7. Environmental factors, workflow and staffing patterns 9. Patient education 10. Quality processes and risk management. Figure 1 NSW Aggregate Scores for 10 Key Elements 13

Core Characteristics Of the 20 core characteristics, 11 had an average aggregate result greater than 50 percent. The lowest core characteristics related to patient information being readily available and strategies to minimise errors with look alike or sound alike medications (35 percent). Of the 20 core characteristics 1, 2, 4, 5, 14 and 15 had the lowest aggregate scores. Figure 2 NSW Aggregate Scores for each Core Characteristic 14

Further analysis of poor performing core characteristics In order to identify areas of concern and required action, the MSSA data from NSW public hospitals was thematically analysed by a multidisciplinary group of seven clinicians including experts in medication management and quality and safety processes. Core Characteristic 1 Essential patient information is obtained, readily available in a useful form and considered when prescribing, dispensing and administering medication. Issues identified: Clinicians lack access to computers to readily retrieve laboratory results because of time constraints or difficulty in accessing computers There is no linkage between ipharmacy and patient information IT systems - especially noted regarding adverse drug reactions (ADRs) The use of bar coding and computerised physician order entry (CPOE) are non - existent across the system Practices relating to sedation scored well, but monitoring of patients observations, especially those with a patient controlled analgesia (PCA) infusion is of concern o 52.5 percent of facilities scored E (fully implemented throughout) for Patients who receive MODERATE SEDATION, PCA, or other infusions to treat pain are monitored for signs of over - sedation at least every 4 hours by evaluating the patient s level of alertness and vital signs including heart rate, blood pressure, respiratory rate and quality of respiration. Core Characteristic 2 Essential drug information is readily available in useful form and is considered when prescribing, dispensing, and administering medications. Issues identified: Clinicians have variable access to computerised drug information systems e.g., CIAP or hard copy medication references such as MIMS CIAP provides useful information regarding medications e.g., MIMS, but often is underused because of difficult computer access, lack of knowledge on how to use the resource, time constraints on the ward or problems with integrating electronic sources of information in daily work flow practices e.g., medication rounds There is a lack of hard copy references such as MIMS, available on ward drug trolleys Responses demonstrate poor performance around high - alert medications across the whole system because: o The majority of hospitals have not identified what is a high alert medication o Systems are not in place to improve safety associated with use of high alert medications Medication reconciliation is not routinely undertaken in the NSW health system. Issues identified include: o Pharmacist numbers/workloads do not allow opportunities for pharmacists to be available at the point of prescribing and to consistently perform clinical activities, such as reviewing and monitoring patients medications o The vast majority of hospitals have no formal process developed for medication reconciliation. Core Characteristic 4 Methods of communicating drug orders and other drug information are standardised and automated to minimise the risk of error. 15

Issues identified: Under half the facilities scored fully implemented for having a list of prohibited, error prone abbreviations established and available (despite their recently state-wide publication and acceptance) Problems occur with transfer of medication related information at points of transfer such as transfer to a different ward or level of care due to different departments using different medication charts (eg ICU and Emergency Dept) Core Characteristic 5 Strategies are undertaken to minimise the possibility of errors with drug products that have similar or confusing manufacturer labelling/packaging and/or drug names that look and/or sound alike. Issues identified Across the state, there has been little uptake of initiatives to reduce the incidence of look-alike, sound-alike medication errors such as the incorporation of TALLman lettering into computer systems Given the obligations imposed by the state contract for pharmaceutical products, it is difficult to seek different (non contract) suppliers for products that have labelling / packaging that looks like other products Core Characteristic 14 Clinicians receive sufficient orientation to medication use and undergo baseline and annual competency evaluation of knowledge and skills related to safe medication practices. Issues identified Most facilities scored poorly in regard to all (including agency) staff, undergoing baseline competency evaluation in medication use Low scores in this area due to: o Definition of baseline competency o Education for clinical staff attended mostly on an ad hoc basis o Pharmacists given limited time for education sessions in new staff orientation programs o Inadequate formalised processes regarding clinicians attending regular education sessions o o Pharmacists availability to undertake education dependant on workload No provision of quarantined time in clinicians workload to attend to quality and safety / education Core Characteristic 15 Clinicians involved in medication use are provided with ongoing education about medication error prevention and the safe use of drugs that have the greatest potential to cause harm if misused. Issues identified Ongoing support and education for clinicians in medication errors is poor Poor use of errors for education. 16

Key Elements and Core Characteristics - Comparison of Metropolitan, Regional/Base and Rural/Remote Hospital Location Analysis by location There was no significant difference in overall scores between AHS (p = 0.086), however the location of the hospital (whether metropolitan, regional/base, or rural/remote) was a significant factor for overall differences in a number of the key elements (p =.010). The differences were demonstrated in: Key Element 1 (Patient information) p =.000 Key Element 2 (Drug information) p =.000 Key Element 3 (Communication of drug orders and other drug information) p =.020 Key Element 4 (Drug labelling, packaging & nomenclature) p =.002 Key Element 7 (Environmental factors, workflow and staffing patterns) p =.000 Key Element 8 (Staff competency & education) p =.032. The four remaining Key Elements were similar across the State. Figure 3: 10 Key Elements* - comparison by location * Refer to Table 1 for listing of elements (kp01 = Key Element number 1, Patient Information). 17

Figure 4: Poor performing core characteristics* (1, 2, 4, 5, 14, and 15) - comparison by location * Refer to Table 2 for listing of Core Characteristics (cp01 = C1 Essential patient information is obtained, readily available in a useful form and considered when prescribing, dispensing and administering medication). In general, the pattern of strengths and weaknesses regarding key elements and core characteristics is similar across hospitals in metropolitan, regional / base and rural / remote locations. 18

Other countries results using MSSA Canada In 2002 Canada adopted the MSSA tool to assist hospitals to identify areas of risk in their medication systems. In 2005 results from 195 facilities that had completed the MSSA was published. The average aggregate score across Canada was 55 percent, but with substantial variations. The key elements showing the highest scores related to management of medication delivery devices, environmental factors and drug standardisation, storage and distribution. Canadian scores were lowest in the key elements of patient information, communication of drug orders and other drug information, staff competency and education and patient education. The highest score for a core characteristic was related to isolating of hazardous chemicals from patients and drug preparation areas. The lowest core characteristic score related to the availability of essential patient information. Comparison of the aggregate scores by hospital demographics such as bed size, type and speciality demonstrated similar patterns of response. Greenall, J., U, D. & Lam, R. An Effective Tool to Enhance a Culture of Patient Safety and Assess the Risks of Medication Use Systems. Healthcare Quarterly; Special Issue; October 2005, 8; 53 58. United States of America In 2003 results from 1,435 participating U.S. hospitals which had completed the MSSA in 2000 were analysed. The average aggregate score across the US was 56 percent. The key elements which scored highest related to drug storage and distribution, environmental factors, and use of medication delivery devises. The key elements that scored the lowest, on average, related to accessibility of patient information, communication related to medications, patient education, and quality processes and risk management. The results from the 2000 study were presented to participating hospitals in the form of a workbook to help them identify and prioritise medication safety initiatives. Smetzer, J., Vaida, A., Cohen, M., Tranum, D., Pittman, M., & Armstrong, C. Findings from the ISMP Medication Safety Self Assessment for Hospitals. Joint Commission Journal on Quality and Safety; November 2003, 29;11, 586 596. It should be noted that the patterns demonstrated in the Canadian and US results regarding poor and good performing Key Elements and Core Characteristics are similar to the results from the NSW MSSA analysis. 19

Summary of findings The main issues identified from the results of the NSW MSSA data analysis include: Inadequate performance in medication reconciliation Inadequate performance around monitoring of patients with patient controlled analgesia (PCA) infusions Poor performance in the handover between pharmacists and clinical staff around patient medication history Limited performance in pharmacist review of patient medications Low use of IT systems e.g., bar coding and computerised physician order entry (CPOE) Non - linkage between pharmacy IT software and other IT systems within the NSW health system Difficulties accessing essential information laboratory results / CIAP / MIMS Lack of formalised high - alert drug list Poor access to and use of approved abbreviation list Limited opportunities for education in new staff orientation sessions and quality improvement and safety activities around medications Lack of uptake of initiative to reduce the incidence of look-alike, sound-alike medication errors such as the incorporation of TALLman lettering into computer systems. Recommendations Completing the MSSA has been a positive and informative process for staff of many facilities across NSW. This process has enabled teams to identify areas of weakness and required action. Identification of weakness alone, however, does not improve patient care. The following actions are recommended to ensure that the data collected from the MSSA will provide meaningful change to individual hospitals and the system as a whole: All facilities that have not yet completed the self assessment make this a priority MSSA teams at each facility should meet, using the findings of this report and their own results, to determine priority medication safety activities for their facility Facilities should complete the tool annually to determine progress towards safer medication use At least one member of the facility MSSA team should join the HSNet MSSA group (a group on a secure website used for sharing information, documents and discussion about the MSSA - https://www.hsnet.nsw.gov.au/login/login.aspx?returnurl=%2fdefault.aspx) Facilities and area health services should share their achievements in medication safety with others through HSNet. 20

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Offices Level 3, 65 Martin Place Sydney NSW 2000 1 st Floor Administration Building Sydney Hospital 8 Macquarie Street Sydney NSW 2000 Correspondence GPO Box 1614 Sydney NSW 2000 Tel 61 2 9382 7600 Fax 61 2 9382 7615 www.cec.health.nsw.gov.au 22