1. QUM Indicator 5.3 A Quality Improvement Program Ensuring explanations for changes to medication therapy in the discharge summary Presenter Insert your hospital logo here

2. Explaining changes on the discharge medicines list Overview Background Aims and methods Educational Intervention Results Questions & Discussion

3. Explaining changes on the discharge medicines list What is the purpose of the discharge summary? Frequently, the discharge summary is the only communication provided to the General Practitioner (GP) about their patients and the events that occurred whilst their patients’ were in hospital.

4. Explaining changes on the discharge medicines list Medication Error and ADEs Transferring patients are those most vulnerable. 1 Poor quality communication 1

5. Explaining changes on the discharge medicines list Identified gaps in practice “Inaccurate, incomplete and illegible” information are common deficiencies within the discharge summary 2 In the medicines list: -Omitted medications 3,4 -Medication not previously prescribed (or justified) 3,4

6. Explaining changes on the discharge medicines list Aims 1.To use drug use evaluation (DUE) methodology to describe the extent to which explanations for medicine therapy changes are being documented in discharge summaries from participating NSW and ACT hospitals. 2. To increase awareness of the APAC Guiding Principles within the hospital setting, in particular “communicating medicines information” (Guiding Principle 9). 5 3. To optimise the discharge summary as a communication tool to General Practitioners (GPs) on explanations for alterations to patients’ medicine therapy.

7. Explaining changes on the discharge medicines list Defining “changes” to and “explanations” for medication therapy? Refers to changes to the patient’s pre-admission regimen which are intended to continue after discharge 2 –New medication –Change in the dose, form, route or frequency of a medicine taken prior to admission –Cessation of a medicine taken prior to admission Explanations for changes: Should include sufficient detail to inform future management decisions in the discharge summary or discharge letter.

8. Explaining changes on the discharge medicines list DUE Methodology Feedback SHPA Drug Use Evaluation Cycle 6

9. Explaining changes on the discharge medicines list Program Methods Ethics approval Support from senior clinicians Data collection Education and Feedback Data collection Evaluation, Feedback and Sustainability August 2010 June 2011

10. Explaining changes on the discharge medicines list Educational Intervention Involved educational and system changes –Location of documented Best Possible Medication History –Discharge Summary Medication Checklist for Term Supervisors –Lanyard Cards –Discharge Summary Workshop(s) –Other

11. Explaining changes on the discharge medicines list Pre and Post-intervention results Hospital NSW/ACTHospital Baseline Post- intervention Patients discharged where a discharge summary is documented in the notes 506/538 (94.1%) Patients who had medication reconciliation undertaken on admission 272/52 # (51.6%) Discharge summaries which comply with NSW Policy (PD2007_092) for a documented list of medications on admission and on discharge 126/506 (24.9%)

12. Explaining changes on the discharge medicines list Pre and Post-intervention results continued HospitalNSW/ACTHospital Baseline Post- intervention Discharge summaries which should have explanations for medicine therapy changes 434/506 (85.8%) Discharge summaries which document all changes to medicine therapy 131/434 (30.2%) Number of medicine therapy changes which require an explanation 1628 Of those, proportion which had a documented explanation for the change 619/1628 (38.0%)

13. Explaining changes on the discharge medicines list Pre and Post-intervention results continued HospitalNSW/ACTHospital Baseline Post- Intervention Of the discharge summaries reviewed, those which were computer generated 460/506 (90.9%) Discharge summary templates prompting documentation for changes to medications 217/506 (42.9%) Number of discharge summary templates reviewed 28

14. Explaining changes on the discharge medicines list Discussion Encouraging aspects of our results Where to from here?

15. Explaining changes on the discharge medicines list Hospital Program Contacts Clinical Champion: xxxxx Local Project Team: xxxxx

16. Explaining changes on the discharge medicines list References 1.Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. National Prescribing service. Sydney, June 2009. 2. Wong JD, Bajcar JM, Wong GG et al. Medication reconciliation at hospital discharge: Evaluating Discrepancies. Ann Pharmacother 2008;42:1373- 1379. 3. Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential. Int J for Qual in Health Care 2005; 17(1):15-22. 4. Perren A, Previsdomini M, Cerutti B, et al. Omitted and unjustified medications in the discharge summary. Qual Saf Health Care 2009;18:205- 208. 5.Guiding principles to achieve medication management: Australian Pharmaceutical Advisory Council; 2005:1-55. 6. SHPA Committee of Specialty Practice in Drug Use Evaluation. SHPA Standards of Practice for Drug Use Evaluation in Australian Hospitals. JPPR 2004; 34(3): 220-222..

17. Explaining changes on the discharge medicines list Acknowledgements NSW TAG –SAFER Medicines Group –Drug Use Evaluation Support Group Indicator 5.3 Expert Advisory Committee

18. Explaining changes on the discharge medicines list Questions/Discussion