Department of Health and Human Services SYSTEM PURCHASING AND PERFORMANCE - MEDICATION STRATEGY AND REFORM SDMS Id Number: Patients Own Medications Policy Effective From: June 2014 Replaces Doc. No: Custodian and Review Responsibility: Contact: Applies to: Policy Type: Policy ID as assigned by Corporate Document and Information Services New SPP- Medication Strategy and Reform Director, Medication Strategy and Reform THO-North, THO-South, THO-North West DHHS wide Policy Review Date: May 2017 Key Words: Routine Disclosure: Approval POMs, pharmacy clinical pharmacist, medicines, discharge, inpatient Yes Prepared by Sulfi Newbold Medicines Policy Officer 61661029 16 May 2014 Through Through Cleared by Anita Thomas Senior Specialist Pharmacist Quality Use of Medicine THO-N Medication Management and Safety Committee THO-NW Medication Safety & Improvement Committee THO-S Quality Use of Medicine Committee John Kirwan Karen Linegar Matthew Daly THO-N Chief Executive Officer THO-NW Acting Chief Executive Officer THO-S Acting Chief Executive Officer 61661086 16 May 2014 16 May 2014 6 June 2014 2 June 2014 3 June 2014 Revision History Version Approved by name Approved by title Amendment notes Name Name Name Position Title Position Title Position Title Page 1 of 7
Purpose The purpose of this policy is to provide guidance for the management of patients own medication (POMs) during inpatient admissions at Tasmanian public inpatient facilities (sites). Patients are actively encouraged to bring POMs with them during an inpatient stay to assist pharmacists and treating doctors to take the best possible medication history (BPMH) and reconcile medications, initiated or ceased during an admission, at the point of discharge. POMs remain the property of the patient but, for safety purposes, must be managed appropriately by THO staff during an inpatient admission. POMs must be stored in accordance with the Poisons Regulations and DHHS policy, and, where appropriate, returned to the patient upon discharge. Compliance with this policy will assist sites to meet The National Safety and Quality Health Service Standard 4 in Medication Safety. Mandatory Requirements POMs to be brought to hospital: Current Medication all the medicines that a patient is taking prior to hospital admission. This includes prescribed, over-the-counter, complementary, alternative and clinical trial medicines. Clinical Trial Medicines - medicines that a patient has been provided as part of a clinical trial (research study) in which they are currently participating. Complementary Medicines - medicinal products containing herbs, vitamins, minerals, and nutritional supplements, homoeopathic medicines, or any other natural or holistic therapeutic agents. Prescribed Medicines - medicines that can only be obtained from a pharmacy, with a written prescription from an authorised prescriber (a medical practitioner, dental practitioner, optometrist, or nurse/midwife practitioner). Over-the-Counter medicines that can be sold to a patient without a prescription (as described above), either through a pharmacy, supermarket, or other retail outlet. Schedule 8 and Schedule 4 Declared Medicines prescribed medicines that are controlled by law due to the high risk of addiction, diversion or misuse. For the purposes of major Tasmanian acute care hospitals, this policy refers to Pharmacists and Pharmacy support staff who can assist with the management of POMs, as well as allocated space within the Pharmacy Department for the secure storage of POMs during an inpatient admission. Inpatient facilities that do not have onsite Pharmacy support must make alternative arrangements for the management of POMs, while maintaining compliance with the principles of this policy. Patients and their carers should be instructed to bring all current medicines, and their medicines list (if applicable), into hospital for each admission wherever possible. POMs must be examined by the admitting medical officer and/or clinical pharmacist at the point of admission, during the medication history interview following admission, or as soon as the POMs are available. Page 2 of 7
At sites without onsite medical officers and pharmacy support, POMs must be examined at the point of admission, or as soon as the POMs are available, by a registered nurse who is trained in taking a medication history. In the interest of patient safety, POMs should not be left in the possession of the patient during a hospital admission unless under an approved self-administration partnership. POMs must be placed in a POMs bag that is clearly labelled with the patient s name and THCI number. A POMs bag must be visually distinctive and recognisable within each site, and described clearly in a local POMs procedure. The patient should be advised that the hospital will provide their inpatient medications, and that their POMs will be returned to them at discharge. Patients must not self-administer medications unless advised to do so, and adequately supervised (*Refer to Use of POMs during Inpatient Admissions of this document). POMs should not be sent home with carers or relatives during the admission process. Wherever possible, a clinical pharmacist should be consulted before POMs are sent home ahead of patient discharge. POMs must be stored in accordance with the manufacturer s directions. POMs must be stored either in compliance with local ward procedures, or relocated to a POMs storage area in the Pharmacy Department (where available). POMs must be transported safely and securely. The storage location of the POMs, and any subsequent movements including the final return of POMs to the patient or carer, must be documented in accordance with local procedures. Schedule 8 (S8) and Declared Schedule 4 (S4D) medicines must be placed in an appropriate S8 or S4D safe, either on the ward or in the Pharmacy Department (where available), and written into a dedicated register titled Patient s Own Medications. Ward transfer If POMs are not stored in the Pharmacy Department (where available) during an inpatient admission, POMs must be transferred with the patient when moved to another ward. Use of POMs during Inpatient Admission The use of POMs for inpatient dosing is not permitted except in circumstances where the item: o Is not available through the Tasmanian Medicines Formulary o Has been prescribed for a pre-existing condition prior to hospital presentation o Is an inhaler or eye drop (or other individual patient medication delivery device) that the patient has in use (expiry date must be marked and valid for it to be used) o Is required for a patient admitted after hours and the required medications are not on imprest. The item must be ordered from the Pharmacy Department as soon as it re-opens and the POMs no longer utilised for inpatient supply. o Is required for a patient admitted to a facility without an onsite pharmacy and the required medication is not on imprest. The medication must be ordered from the relevant Pharmacy Department as soon possible, and the POMs no longer utilised for inpatient supply once the medication has arrived on site. In all these circumstances the medications must be accurately charted on the National Inpatient Medication Chart (NIMC). Nursing and midwifery staff must be satisfied that any POMs to be administered during an inpatient admission belong to the patient for whom it is intended, are in date and good condition, and clearly identified as the medicine required for administration. Page 3 of 7
Discharge If POMs have been stored on a ward during a patient s admission, POMs must be sent to the Pharmacy Department (where available) with the discharge prescription for dispensing. POMs must be reviewed as part of the discharge process. POMs Review As a minimum standard, a POMs review, as part of the discharge process, must include: Confirming that the POMs are being returned to the right patient, Checking that POMs are in date and suitable for use, and Ensuring the patient is aware of any medication changes that have been effected during the hospital admission. Wherever possible, a pharmacist must reconcile the POMs with the current discharge prescription, as per the DHHS: Medication Management Policy. Medication Reconciliation at Discharge A reconciliation of POMs with the discharge prescription should include: A check to ensure POMs comply with the current discharge prescription with respect to: Drug Strength Dose Whenever possible, a full medication list entered into the dispensing software to document a best possible medication history for the patient. POMs, and items that are not required, must be entered into the patient s profile and marked as own supply. Re-labelling of POMs with appropriate directions in situations where the only discharge changes relate to dose, or frequency of administration. POMs that comply with the current prescription with respect to drug, strength, dose, frequency of administration, and which have not exceeded the expiry date, must be returned to the patient unchanged. POMs which are no longer part of the patient s therapy must be placed IN A SEPARATE SEALED BAG and labelled appropriately to indicate they have been ceased and returned to the patient. Patients should be encouraged to dispose of ceased or expired medicines at discharge. Unwanted or expired POMs must be destroyed via Pharmaceuticals for Destruction (PFD) bins (or similar) available in the Pharmacy Department of major, acute-care public hospitals, or as per local protocol at other sites. POMs must never be added to Pharmacy Department stock, as per the DHHS: Policy for the Management and Disposal of Unwanted Medicines. Uncollected POMs POMs not collected within one month of the discharge date must be destroyed via a Pharmaceuticals for Destruction (PFD) bin (or similar). This must be documented and recorded appropriately. Page 4 of 7
S8 or S4D POMs that are not collected, or are no longer required, must be destroyed in accordance with state legislation, and recorded appropriately. Lost POMs Lost POMs must be reported to the relevant nurse in charge, clinical pharmacist or Pharmacy Department (where available), and via the approved incident reporting system (Safety Reporting and Learning System (SRLS)) as soon as is practicable. If the patient is not satisfied that an appropriate resolution has been reached in relation to lost POMs, the complaint should be referred to the hospital Consumer Liaison Office (or equivalent) within each THO. Lost S8 or S4D POMs should be managed in accordance with the local protocol for other lost S8 and S4D medications, and in accordance with SPP-MSR: Schedule 8 and Declared Schedule 4 Medicines Management Policy. Roles and Responsibilities/Delegations It is the responsibility of clinical staff (nursing, medical, or pharmacy) to ascertain whether a patient has POMs with them at the point of admission. POMs not available at admission should be brought in by carers or relatives, on behalf of the patient, as soon as is practicable. Medical officers and pharmacists are responsible for assessing POMs and obtaining a best possible medication history during an admission interview, or soon after. It is the responsibility of nursing and pharmacy staffs to safely store and document the whereabouts of POMs appropriately. Nursing staff are responsible for retrieving, transferring and documenting the movement of POMs within the hospital when a patient moves to another ward. It is the responsibility of nursing staff and/or clinical pharmacists to retrieve POMs from ward storage, where applicable, and send to the Pharmacy Department (where available) with the discharge prescription when available. The preferred health professional for a full medication reconciliation (as described under Discharge in the Mandatory Requirements section of this policy) is a clinical pharmacist. If the discharge prescription is not processed by the hospital Pharmacy Department, a POMs review (as described under Discharge in the Mandatory Requirements section of this policy) is the responsibility of the treating medical officer. Wherever possible, it is the responsibility of the clinical pharmacist to appropriately counsel patients on all discharge medications, including new medications, medications ceased, POMs relabelled, or POMs returned unchanged. In circumstances in which a clinical pharmacist is not available, it is the responsibility of the discharging medical officer to communicate any medication changes, and return the reviewed POMs (as described under Discharge in the Mandatory Requirements section of this policy) appropriately. It is the responsibility of all clinical staff involved with returning POMs to the owner (the patient) to facilitate the disposal of ceased or out-of-date POMs via a PFD bin (or similar), if the patient s permission has been obtained. It is the responsibility of nursing and pharmacy managers to ensure all staff involved in the handling of POMs is aware of this policy and compliant with the mandatory requirements. Page 5 of 7
Risk Implications The major consideration in the appropriate management of POMs is to increase patient safety during an inpatient admission and at discharge, by: Reducing medication charting errors on admission Reducing medication duplication on discharge, Clarifying medications initiated and ceased during inpatient stay, Reducing high-risk medication diversion by recording and tracking of S8 and S4D POMs, Reducing the use of expired or damaged medicines, Well managed POMs will also reduce medication waste, and reduce the occurrence of loss and subsequent replacement of POMs following patient discharge. Training All new nursing, medical and pharmacy staff must be orientated to this policy as part staff induction, and introduced to all aspects of POMs management, as described in a local procedure. Training must include appropriate POMs storage and documentation. Audit All Patient s Own Medication S8 and S4D medicines registers must be kept for a minimum period of TWO YEARS and made available upon request for audit by the Pharmacy Site Manager, or an external agent such as the Pharmaceutical Services Branch. All other documentation of POMs storage and transfers, and all records of POMs returned to a patient or carer, must be kept for a minimum period of ONE YEAR and made available upon request for audit by the Pharmacy Site Manager. This policy will be included in the work program of the DHHS Internal Audit function. This work program is approved by the Audit and Risk Committee and will assess underlying systems and procedures for compliance with the requirements of this policy. The overall focus of this assessment will be one of continuous improvement to DHHS activities. Attachments 1 The Poisons Act 1971 2 The Poisons Regulations 2008 3 SPP-MSR: Schedule 8 and Declared Schedule 4 Medicines Management Policy 4 SPP-MSR: Management and Disposal of Unwanted Medicines Policy 5 SPP-MSR: Medication Systems and Management Policy 6 SPP-MSR: The Use of the National Inpatient Medication Chart Policy Page 6 of 7
7 DHHS: Incident Reporting and Management Policy 8 Safety Reporting and Learning System Page 7 of 7