PATIENT SAFETY
chance of falls, adverse drug reactions, cognitive impairment, non-adherence and poor nutritional status.
The 5 Moments for Medication Safety tool
This is a tool developed as part of the global patient safety challenge and is a patient engagement tool which focuses on five key moments where action by the patient or caregiver can reduce the risk of harm associated with the use of medication/s. It is suggested that the questions can be put by the patient or family, to the healthcare professional. The 5 Moments for Medication Safety tool can be applied at different levels of care and in different settings and contexts. It can be used when patients:
l Visit a primary healthcare facility l Are referred to another healthcare facility or to another healthcare professional
l Visit a pharmacy l Are admitted to a healthcare facility l Are transferred to another healthcare facility l Are discharged from a healthcare facility l Receive treatment and care at home or nursing home.3
The “5 Moments” are when a patient starts a medication, when taking a medication, when adding a medication, when reviewing medications and when stopping medications. The 5 Moments propose questions to be asked in the ‘moment’, such as: “Do I really need another medication?” and: “What are the risks and possible side effects?” The purpose is to inform patients and to get them more involved in their own care and the beginning of responsibility for the medications which they consume.
This will undoubtedly educate patients better towards their own management but in many instances, particularly in primary care where the majority of prescribing takes place, time will be even more pressed than it is currently.
Medication in high risk situations
There are lists of medicines which are considered to be high risk or (high alert) involved in the technical reports which suggest strategies that countries may wish to promote so that there is greater understanding and fewer opportunities for high risk medications to cause harm. The WHO suggests that local lists of high risk/ high alert medicines would help healthcare professionals to be extra vigilant when they are prescribing or administering them. The lists would need to be dynamic, accessible to all and have local risk reduction strategies developed to reduce the potential for harm. In addition, it is useful to have a strong local culture of safety and reporting as well as education and feedback. National solutions are suggested as likely to be the most effective.
One of the solutions which has been effective in reducing harm is the development of standardisation and
systematisation of processes and documentation – which includes naming, packaging and labelling. In addition, prescribing errors were shown to be significantly reduced when a standardised prescription chart was introduced in Queensland and then across Australia. Further standardisation has resulted in national terminology, abbreviations and symbols to be used across all prescribing and administration of medicines in Australia. Wales has similarly introduced a national chart which has subsequently been endorsed by the Royal College of Physicians as an example of good practice. Reporting and learning systems and pharmacovigilance centres have developed where a strong safety culture is devised which includes the anticipation of errors, where risks are proactively assessed and managed and where healthcare professionals feel comfortable and confident to discuss and report errors and near misses and learn from them.
The use of multiple strategies helps health systems to manage the complexity of addressing and reducing risks. The Institute for Safe Medication Practices suggests further measures, such as: l Several risk reduction strategies may be used together
l Strategies may be chosen that influence as many steps of the medication management system as possible
l “High-leverage” risk reduction strategies, such as forcing functions and standardisation, may be bundled together with “low-leverage” strategies, such as staff education and passive information dissemination
l The strategies that are chosen should be sustainable.4
Medication safety in polypharmacy
As already stated, there is a dearth of evidence on polypharmacy due to the traditional method of medical research being focused on single diseases. In addition, it is
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slightly difficult, as the term continues to lack a clear definition. A recent systematic review showed the term was most commonly applied to situations where patients took more than five medicines.5
Furthermore, it
is inconsistent in the literature as to whether over the counter and herbal remedies should or should not be included when discussing polypharmacy. Conventionally polypharmacy has been perceived as an overuse of medicines, whereas it may be more useful to perceive in terms of appropriateness, as there are many cases where the concurrent use of multiple medicines may be deemed necessary and beneficial.6
All stakeholders have a vital role to play in driving change for the management of polypharmacy. Polypharmacy management involves multifaceted decision-making and necessitates the combined knowledge of physicians, nurses, pharmacists and other healthcare professionals, including the systematic involvement, engagement and empowerment of patients. Medication reviews and reconciliation are suggested combined with good communication and accurate sharing of information with patients and their carers or families. Implied in the process is the potential for re-design of care processes and or services which the patient receives, in order to manage the workload related to polypharmacy and improve medication safety.
The role of pharmacists is heavily emphasised in this report as well as the role of apps to support patient and medical education during the prescribing process. A report on polypharmacy undertaken across several countries in EU suggests that up to 11% of unplanned hospital admissions are attributable to harm from medicines and over 70% of those are due to elderly patients on multiple medications, there are significant opportunities to reduce the burden by timely and effective interventions.7
There are six key recommendations on managing polypharmacy effectively and these are: l Use a systems approach that has multidisciplinary clinical and policy leadership
l Nurture a culture that encourages and prioritises the safety and quality of prescribing
l Ensure that patients are integral to the decisions made about their medications and are empowered and supported to do so
l Use data to drive change l Adopt an evidenced based approach with a bias towards action
l Utilise, develop and share tools to support implementation.
Medication safety at transitions of care
Transitions are defined as the various points where a patient moves to or returns from a particular physical location or makes contact with a healthcare professional for the purpose of receiving healthcare.8 Transitions are often associated with
NOVEMBER 2019
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