HealthCERTAged Residential Care

Medication Management Audit Data Comparison 2009 and 2012

Dr Michal Boyd, RN, NP, NDSr Lecturer and Gerontology Nurse Practitioner

School of Nursing and Freemasons’ Department of Geriatric MedicineUniversity of Auckland

OPAL Results: MedicationsMean number of medications for all

residents in 1993, 1998 and 2008

4.45

7.2

0

1

2

3

4

5

6

7

8

1993 1998 2008

Medications

7.2

7.6

7.3

7.2

6.5

6.5

5.4

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0

ALL FACILITIES

REST HOME

PALLIATIVE

PRIVATE HOSPITAL

RESPITE

PSYCHOGERIATRIC

DEMENTIA CARE

Mean Number of Medications

Mean Number of Medications Taken in the Last 24 Hours for Each Facility Type

2008 mean number of medicationsby care type

Development of ARC Medication Guidelines

• November 2009 HealthCERT analysed 320 audits against the 2008 standards (introduced on 1 June 2009)

– 140 audits (44%) medicine management partial attainment

• MOH contracted Dr Michal Boyd to work with sector representatives to develop a safe management of medicines guide for residential aged care. Completed in 2011.

HealthCERT Auditing Process ChangesSince 2009,

– increased accreditation of auditors

– HealthCERT spot audits

– publishing audit summaries online

– Increased medication management and compliance training for auditors by HealthCERT

– Introduction of the Medication Care guides

Medicines Care Guides (MOH 2011)

• The aim of the Medicines Care Guides is to provide a quick medicine management reference tool for all care staff working in residential aged care in New Zealand.

• Guidance is provided for key medicine safety topics relevant to the care of older adults.

• This guidance is based on current legislation, best available evidence and published guidelines,

• “Ground up” development process

48 Medicines Care GuidesTwo Main Functions

Goal is to improve compliance and care quality:

• General medication safety guides for residential aged care

• Information about specific high risk medications

Comparison of Medication Management Audit Data

• July 2009 and June 2010 (561 Facilities) and January to December 2012 (516 Facilities)

– The data were in free text format within an Excel spread sheet

– One column was used for each of the eight categories of evidence contained in the auditor’s notes

– Each record was highlighted and numbered according to the theme and the category that had been developed from the baseline 2010 report.

Medication Management CategoriesCategory Description

Medicines management system A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.

Policies and procedures Policies and procedures clearly document the service provider’s responsibilities in relation to each stage of medicine management.

Staff competence Service providers responsible for medicine management are competent to perform the function for each stage they manage.

Allergies procedures A process is implemented to identify, record, and communicate a consumer’s medicine allergies or sensitivities and respond appropriately to adverse reactions or errors.

Self-administration procedures The facilitation of safe self-administration of medicines by consumers where appropriate.

Recording and communicating medication management information

Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.

2010 only: Accounting for resident and others' views

Continuity of treatment and support is promoted by ensuring the views of the consumer, their family/whānau of choice where appropriate and other relevant service providers, for example GPs, are considered and documented prior to administration of new medicines and any other medical interventions.

2012 only: Consumers receiving medicines in a safe manner

Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

TABLE 1: COMPARISON OF AUDIT CATEGORY PARTIAL ATTAINMENT PERCENTAGES: 2010 AND 2012

2010 2012 Category % Partial attainments % Partial attainments p value Medication Management Systems 25.7% 45.0% < .001 Policies and Procedures 2.9% 0.8% .01 Staff Competence 12.7% 11.2% .48 Allergies Procedures 4.1% 5.2% .38 Self-administration 5.5% 8.1% .09 Recording and communicating 19.4% 21.3% .45 medication management information Listening to residents’ and others’ views 0% - Consumers receiving medicines - 3.5% In a safe and timely manner

Medication Management 2010 2012 Medication management systems 25.7% 45.0%* category partial attainments (144 of 561 audits) (232 of 516 audits) *p< .001 TABLE 1: MEDICATION MANAGEMENT SYSTEMS RISK LEVEL CATEGORIES: 2010 AND 2012 Level of Risk 2010 PA risk category % (count) 2012 PA risk category % (count) Negligible 0.4% (1) 0 Low Risk 11.6% (65) 14.0% (72) Moderate Risk 10.3% (58) 26.0% (134)* High Risk 3.7% (21) 5.0% (26) Critical 0 0 *p< .001

Medication Management

• Only one sub-category improved significantly in 2012 compared to 2010. This category was:

– Staff competency updating and recording PAs decreased significantly in 2012 (0.4%) compared to 2010 (2.1%).

– Unused medications not returned to pharmacy category showed slight improvement in 2012 compared to 2010 but it was not statistically significant.

Medication ManagementSigning documentation and records: Pas 8.4% in 2010 and 17.8% in 2012, p<.001, Examples:

– Failure to sign medication charts– Controlled drugs checking– Fridge temperatures

Administration of medications: PAs 3.2% 2010 and 16.9% 2012 (p<.001), Examples:– medications not being administered at the right time of day – not being administered when prescribed,– medication being left out.

Labelling of medications absent/unclear: 0.9% 2010 and 11.6% 2012 (p<.001), Examples– eye-drops that had been opened with no date recorded of the opening date.

Controlled drugs checking and record keeping: 7.5% 2010 and 10.1% 2012 (p<.001), – carrying out the weekly controlled drug checks.

Transcribing medications and prescription onto charts: 1.2% 2010 and 7.0% 2012 (p<.001)

Medication Management (Cont)

Three monthly medication reviews not completed by GP: 1.6% 2010 and 4.1% 2012 (p<.001)

Standing orders procedures inadequate or not followed: 1.2% 2010 and 2.9 % 2012 (p<.05)

No resident photo identification : 1.1% 2010 and 2.7% 2012 (p<.05)

Documenting and record keeping 5.7% 2010 and 8.3% 2012 (ns)– failure to document processes following medication lapses– failure to administer warfarin– lack of evidence showing doctor’s signatures.

Medication reconciliation and Medication errors were not significantly different between 2010 and 2012.

Nurse Practitioners in Aged Residential Care

• National contract included Nurse Practitioners– Can do admission and quarterly assessments

• Nurse Practitioner Intern Positions have been created in ARC

• NP in aged care evaluation - >20% fewer hospitalisations

(Peri, Boyd, Stillwell & Foster, 2013, Health Workforce New Zealand)

Medication Management (Cont)

Expired Medications in Use 1.2% 2010 and 6.8% 2012 (p< .001)

Storage of medications: 6.4% 2010 and 9.3% 2012 ( (p = 0.07) • security of storage, • maintenance of the fridge temperature• storage of medications within the main fridge used for foods

Maintaining and using medication charts: 1.2% 2010 and 4.8% 2012 (p<.001)

Block signing document: 1.2% 2010 and 3.9% 2012 (p<.001)

Three monthly medication reviews not completed by GP 1.6% 2010 and 4.1% 2012 (p<.001)

Medicines Care Guides:Medication Storage

Policies and Procedures 2010 2012 Policy and procedures 2.9% 0.8%* category partial attainments (16 of 561 audits) (4 of 516 audits) *p= .02

TABLE 1: POLICY AND PROCEDURES RISK LEVEL CATEGORIES: 2010 AND 2012

2010 2012 Level of Risk PA risk category % (count) PA risk category % (count)_________________________________________________________________________________ Negligible 0 0 Low Risk 1.6% (9) 0.2% (1)* Moderate Risk 1.2% (7) 0.6% (3) High Risk 0 0 Critical 0 0 *p= .04

Policies and Procedures (NS)

Staff Competence 2010 2012 Staff competence 12.7% 11.2% category partial attainments (71 of 261 audits) (58 of 516 audits) All changes non-significant TABLE 1: STAFF COMPETENCE RISK LEVEL CATEGORIES: 2010 AND 2012

Level of Risk 2010 PA risk category % (count) 2012 PA risk category % (count)_________________________________________________________________________________ Negligible 0% (0) 0.2%(1) Low Risk 5.0% (28) 5.1% (26) Moderate Risk 6.4% (36) 5.8% (30) High Risk 1.2% (7) 0.2% (1) Critical 0 0 All changes non-significant

Medication Administration

Registered nurses can:Check and administer all prescribed

medicinesAssess and monitor for effect or

reaction

Enrolled nurses can:

Check and administer oral, topical andrectal medicines and intramuscular and

subcutaneous injections under the direction

and delegation of a registered nurse.

Health care assistants/caregivers can:

Check and administer oral, topical andrectal medicines and under the

directionand delegation of a registered nurse

(eg,oral from a unit dose pack [blister pack] topical medicines,

suppositories)

InsulinAdministration specific competence is

required for administering subcutaneous

insulin.

Staff Competence

Allergies Procedures 2010 2012 Allergies procedures 4.1% 5.2% category partial attainments (23 of 561 audits) (27 of 516 audits) TABLE 1: ALLERGIES PROCEDURES RISK LEVEL CATEGORIES: 2010 AND 2012

2010 2012 Level of Risk PA risk category % (count) PA risk category % (count)______________________________________________________________________________ Not applicable 6.2% (35) Negligible 0 0 Low Risk 1.8% (10) 1.7% (9) Moderate or High Risk 2.3% (13) 3.5% (18)

Allergies Procedures

Self Administration 2010 2012 Self-Administration 5.5% 8.1%* Total Partial Attainments (31 of 561 audits) (42 of 516 audits) Not applicable 1.4% (8) 0 *p= .01 TABLE 1: SELF ADMINISTRATION RISK LEVEL CATEGORIES: 2010-2012

2012 Level of Risk PA risk category % (count) Negligible 0 Low Risk 4.5% (23) Moderate Risk 3.5% (18) High Risk 0.2% (1)

Medicines Care Guides: Self Medication

Self Administration

Recording and Communicating Medicines Management Information

2010 2012 Recording and communicating medicines management information 19.4% 21.3% category partial attainments (109 of 561 audits) (110 of 516 audits) No significant differences

TABLE 1: RECORDING AND COMMUNICATING MEDICINES MANAGEMENT INFORMATION RISK LEVEL: 2010-2012

Level of Risk 2012 PA risk category % (count)_____________________________________________________ Negligible 0 Low Risk 5.0 % (26) Moderate Risk 14.9% (77) High Risk 1.4% (7) Critical 0 No significant differences

Recording and Communicating Medicines Management Information

Documentation2010 2012

% of total Audits

% of total audits

Documents/records not signed or unclearly signed

8.4% 9.9%

Recording of GP 3 monthly reviews 3.9% 3.1%Evidence of controlled drugs checking absent

7.5% 3.3%*(p= .004)

Records relating to allergies or medications absent or unclear

2.1% 3.9%

Documentation illegible or unclear1.8% 1.7%

*2010-2012 difference significant to p=0.05 or less; increased PAs between in 2010 to 2012 in bold.

Recording and Communicating Medicines Management Information

Documentation 2010

2012

Stock taking of medications 1.6% 2.5%Recording medications expiry dates 0.9% 0.4%

Block signing of documents1.2% 4.3%*

(p= .001)

GP 3 monthly reviews out of date 1.6% 1.2%Documenting allergies information 0.5% 0.0%

No photo ID for all residents for recognition when administering medications

1.1% 1.0%

Recording times and dates of medications 0.5% 4.1%*

(p< .001)

Transcribing medications and prescriptions onto charts

1.2% 4.5%*(p= .003)

*2010-2012 difference significant to p=0.05 or less; increased PAs between in 2010 to 2012 in bold.

Recording and Communicating Medicines Management Information

• 2012 - 110 providers PAs– 70% moderate risk– 23% regarded as low risk– 7% facilities were considered high risk in this

field.

• Main issues:– documents and medication records being signed– block signing of medications by GPs.– Transcribing of medications by the RN

TABLE 1: CONSUMERS RECEIVE MEDICATION IN A SAFE AND TIMELY MANNER RISK LEVEL CATEGORIES 2012

2012 (only) Level of Risk PA risk category % (count) ______________________________________________ Negligible 0.4% (2) Low Risk 1.6% (8) Moderate Risk 1.4% (7) High Risk 0.2% (1) Critical 0 Total Category PAs 3.5% (18)

Recording and Communicating Medicines Management Information

Listening to resident and others’ views• Category not in the 2012 database • In 2010, no issues were identified

• 555 of 561 records were reported not applicable

• The remaining 6 achieved full attainment

• This standard pertains more to mental health residential care rather than aged residential care

What is not measured?

Subjective clinical indications, e.g.

• If the correct type medications are used in the correct situation

• Side effects and adverse effects

BUPA Anti-Psychotic Initiative

Bupa Dr Maree Todd ANZSGM June 2013 34

Where to from here?• National Medication Chart

– developed by Health Quality and Safety Commission– standardise medication records to reduce potential errors due

to clinician unfamiliarity with medication documentation– Introduced into public hospitals– Will be rolled out to ARC facilities in the near future

– has the potential to decrease issues identified in this report such as:

• maintaining and using medication charts• block signing documents• three monthly medication reviews not completed by the General

Practitioner.

Electronic Medicines Management System• Software to manage the charting of medication in aged care

facilities

• Prescribers can manage individual patient medicines charting from any location through a secure access

• Reduces the time spent by prescribers, facilities and pharmacists managing the charts

• Ensures an up to date current chart is continuously available, to all users (GP, Community Pharmacy, Aged Care Facility, Hospital Specialists and Nurse Practitioners), at the same time

Electronic Medicines Management System will:• Record administration of all medicines by staff

• Record medicines that haven’t been given and reason/s why

• Allow reporting by patient, unit or facility to allow prescriber's to make better informed clinical decisions

• Provide reporting on individual medicines, a therapeutic group etc.

• Provide robust authentication for charting and updating when a prescriber saves the new item/change, and notification of a change is directed to the care facility and the pharmacy for supply.

• Track medicine supply quantities. This will to reduce medicine wastage and ensure prescriptions exactly match the supply required within a medication cycle.

Recommendations• Ministry of Health will continue to raise medication management

by working closely with the sector

• Road Shows regarding identified themes and trends such as:– GP and RN documentation management

• Encourage DHB and ARC provides to enable education about medication management

• Continue to work with auditors regarding medication management

• Standardised sub-category classifications for audit report

Thank You!

Questions?