Agenda

DAY ONE: Wednesday 7 December 2011

8.30am Registration and welcome coffee

KEYNOTE OPENING ADDRESS

9:10am Closing the gaps in national medication safety and quality: An update on major national medication safety initiatives

• Standardisations to reduce medication errors
• Improving continuity of care
• Reducing gaps in practice
• Safety in e-health

Graham Bedford, Policy Team Manager, Australian Commission on Safety and Quality in Health Care

NATIONAL INITIATIVES

9:50am Prevention of Venous Thromboembolism in Australia

• A national implementation program to address an international patient safety issue in hospitals - blood clots and the underutilisation of thromboprophylaxis
• Examples of hospital strategies to promote appropriate prescribing and patient awareness of thromboprophylaxis
• Building local and national awareness through multidisciplinary collaborative efforts and shared responsibility

Zoe Kelly, Acting Assistant Director, National Institute of Clinical Studies, National Health and Medical Research Council, Vic

10:10am User-applied labelling in Victorian hospitals: Examination of current practices

• Implementing the Australian Commission on Safety and Quality in Health Care’s (ACSQHC) National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines has been a priority for many organisations
• Identifying the current actual practice and the potential barriers to implementation
• Audit development of a state-wide pre-implementation audit of user-applied labelling
• Role of the Victorian Therapeutic Advisory Group (VicTAG) Quality Use of Medicines (QUM) Group

Wendy Ewing, QUM Pharmacist, Southern Health

10.50am Morning Tea
 

USE OF TECHNOLOGY AND ELECTRONIC SYSTEMS

11.20am Using an Electronic Management System to safely manage medicines and deliver expected benefits

• Reduction in overall prescribing error rate by more than 50% and 95% completed allergy status.
• Incorporation of NIMC and ACSQHC medication safety initiatives and standards
• Eradication of illegible handwriting, error-prone abbreviations, acronyms and leading zeros
• Configurable clinical decision support providing safe practice information – concise and consistent at the point of patient care
• Reduction of risk by ensuring only accredited staff perform legislated and policy mandated tasks
• Developed systems and practices to ensure ongoing sustainability

Katrina Richardson, Clinical Information Systems Pharmacist, St Vincent's Hospital, Sydney

12.00pm Reducing IV Infusion Errors: Experience of wireless enabled smart infusion pumps and real time alerts across a major multi-hospital network

• Implementation of a comprehensive wireless IV infusion drug library for use in 631 IV pumps across 3 sites in a multi campus health service
• Experience from Australia’s first wireless IV infusion drug library and quality improvement reporting system
• Leading improvements through the application of innovative wireless IV infusion libraries that enable real time updates and improvements

Mona Mostaghim, Senior Pharmacist, Medication Safety, Alfred Health

12.40pm Lunch
 

STRATEGIES FOR THE ACUTE SETTING

1.40pm Responding to Medication Safety Alerts – Reducing the risk associated with concentrated intravenous potassium

Over 8 years, a multifaceted approach has been taken to reduce risk associated with the use of concentrated potassium across Queensland Health facilities. Multiple strategies have been implemented state-wide.

Carol Reid, Acting Senior Clinician Manager, Medication Services QLD

2.20 CASE STUDY: A Multidisciplinary Approach to Safe Prescribing of Enoxaparin

Enoxaparin is an anticoagulant commonly used to treat acute coronary syndromes, deep vein thrombosis and pulmonary embolism. In contrast to other anticoagulants such as heparin and warfarin, enoxaparin was marketed with the promise that no drug monitoring was required. Six major adverse events related to enoxaparin treatment were reported at The Prince Charles Hospital from 2002 to 2008. This presentation will discuss:

> Key risk factors (patient, practitioner and process) for major adverse events related to enoxaparin treatment
> Strategies for change including providing access to a decision support tool at the point of care, staff education and standardised process for prescribing and monitoring
> Outcomes to date
> Importance of incident review and auditing in improving the safety of high risk medications
> Ongoing challenges with anticoagulants

Bonnie Tai, Specialist Pharmacist (Safety & Quality), The Prince Charles Hospital

3.00pm Afternoon Tea

3.30pm Embedding standardised capture and transfer of accurate medication information in the acute care setting

• Outline and assessment of problem
• Development, trial and implementation of the Medication Action Plan to guide continuity in medication management
• Measurement of improvement
• Lessons learnt

Carol Reid, Acting Senior Clinician Manager, Medication Services QLD

4.10pm Implementation of multiple initiatives to improve prescribing practices and medication safety in an acute medical unit

• The National Inpatient Medication Chart (NIMC) is a communication tool
• Prescribing errors on the NIMC contribute to adverse drug events among hospitalized and discharged patients
• Multiple quality improvement initiatives were implemented including: academic detailing, use of the National Prescribing Service NIMC online education tool and in-service education of nursing staff
• There was improvement in prescribing practices following implementation of the initiatives

Davina Gillard and Madeline Khor, Intern Pharmacists, Royal Adelaide Hospital

4.50pm IIR invites all speakers and delegates to an informal networking drinks reception

DAY Two: Thursday 8 December 2011

8.30am Morning Coffee

9.00am Opening remarks from Chair

MEDICINE MANAGEMENT IN VULNERABLE GROUPS

9.10am Medication Incidents in Children situated in inpatient and outpatient environments

• Identifying the types of medications involved in medication incidents for children
• Identifying the types of medication incidents occurring in children
• Describing the causes of medication incidents for children
• Identifying possible strategies that can be implemented to prevent future occurrence of medication incidents

Sharon Kinney, Lecturer in Nursing, The University of Melbourne

9.50am Medication Errors in Older People

• Age-related changes in pharmacokinetic and pharmacodynamic in older people
• The challenges of managing multiple medicines
• Implications for reducing medication-related harms and achieving quality use of medicines

Andrew McLachlan, Associate Dean (Research), Professor of Pharmacy (Aged Care), University of Sydney, Chair of Pharmacy (Aged Care) based at Concord Hospital

ENCOURAGING EDUCATION, PATIENT INVOLVEMENT and A MULTIDISCIPLINARY APPROACH

10.30am Morning tea

11.00am Engaging Patients and Medical Staff in Medication Safety

• Engaging Patients –The Speak-Up Campaign: Results of a Pilot Study
     - The campaign aimed to encourage patients to take a role in medication safety by becoming actively involved and informed participants in their medication management
• Engaging Medical Staff – The Use of Clinical Pharmacist’s interventions as an educational and awareness tool
     - Nomination of interns as medication safety ambassadors and representatives on the Medication Safety Committee alongside senior medical and nursing staff assisted in raising medical safety awareness amongst junior medical staff
     - Circulation of selected de-identified clinical pharmacists’ interventions to all levels of medical staff for use as an educational tools to promote awareness and discussion of near miss medication errors

Jan de Clifford, Senior Pharmacist, Frankston Hospital

11.40am Interprofessional communication, education and training: Tackling errors in clinical reasoning
Debra Rowett, Clinical Pharmacist, Director of the Drug and Therapeutics.Information Service, Repatriation General Hospital

12.20am Lunch

1.20pm A Sustainable Model for Medication Safety

Based on incident reports and audits, two areas were identified for improvement at The Prince Charles Hospital. 1) prescribing, reconciliation
and documentation; and 2) management of high risk medications. In 2003, the Medication Management Team was formed and has undertaken a number of medication safety initiatives in the hospital. The biggest challenges faced by the team were to measure the effects of changes and to sustain the improvement. The presentation will discuss:

• Roles of the Medication Management Team
• Importance of multidisciplinary involvement in medication safety
• How to plan for and measure sustainability for medication safety
• Measuring adverse drug events using the IHI Global Trigger Tool

Dr Helen Ward, Director of Patient Safety, The Prince Charles Hospital

2.00pm New and Emerging Medication Trends in Nurse Prescribing

• In Australia, the Nurse Practitioner (NP) was introduced in 1998 with prescriptive authority in some jurisdictions commencing in 2001.
• Recent legislation to allow NPs and midwives access to the PBS and the MBS has once more brought non-medical prescribing, in particular NP prescribing, into the public arena.
• This presentation will present findings from a recent National Survey of NP prescribing behaviours and present trends in prescription practices in recent years

Tom Buckley, Coordinator Master of Nursing (Nurse Practitioner), University of Sydney

2.40pm Afternoon Tea

3.10pm 'Take my tablets before breakfast' – Promoting People's Independence in Managing Medicines in the Community

• An integrated, person-centred approach to self management of medicines in the home
• Application of Active Service Model principles (Department of Health,Victoria) to promote independence with self administration of medicines
• Development of an RDNS Medicines Care Pathway
• Development, implementation and evaluation of Medicine Prompt Cards

Ann Johnson, Senior Nursing Support, Royal District Nursing Service

3.50pm Improving medication management for culturally diverse communities

• Background of the CALD population in Australia – specifically in relation to health outcomes and medicine management
• Discussion of the Medication-Improving Management study conducted by RDNS
• The Journey of Medicine Management in the community
• Future directions for medicine management in the community

Fleur Duane, Project Officer, Royal District Nursing Service

4.20pm Nurse's Perceptions and Role in Preventing Medication Errors

• Overview of paediatric population in relation to medication errors and safety
• Role of nursing staff in medication safety
• Implementation of the independent double check
• Factors influencing the quality of the independent double check, including safety culture and influence of senior nursing staff
• Future recommendations to reduce risk of medication error

Elesha Toscano, Nurse Educator, Mater Children's Hospital

5.00pm Closing Remarks from the Chair

5.10pm Close of Conference

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