Medication Safety: Resources

INTERPROFESSIONAL EDUCATION FOR QUALITY USE OF MEDICINES (IPE for QUM)

This website profiles five authentic situations (see below) in which poor interprofessional communication and teamwork resulted in adverse medication events outcomes.

http://www.ipeforqum.com.au/modules/

1.     Vanessa Anderson

This module portrays Vanessa’s story and is based upon the findings from the Coroner’s report into her death in 2005. Although Vanessa’s death resulted from a combination of human and systems errors, this module will focus primarily on the communication and medication safety issues that occurred during Vanessa’s hospitalisation. As you undertake this module carefully consider how the poor communication between the health professionals involved impacted upon medication safety and how this could have been prevented. At the same time reflect on how your learning will impact your future practice.

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2.     Mark Green

This module was adapted from an actual clinical case in which a serious clinical error occurred and this resulted in a person’s death. The coroner’s report following the inquest identified communication between staff and during handover, documentation and clear identification of decisions, and use of appropriate guidelines and protocols as key areas for improvement.

There is also a Japanese version of this module available on the module page.

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3.     Gavin Sinclair

This module introduces 23 year-old Gavin Sinclair, who presents to the emergency department at a regional hospital after a minor car accident.  A physical examination has cleared him of any physical injuries but Gavin’s mental state is of concern to staff.  Undiagnosed and inadequately treated schizophrenia has a high burden of illness in the Australian community. Evidenced-based treatment for schizophrenia includes antipsychotic medications and ongoing monitoring. However, non-adherence to medication is common and stigma associated with schizophrenia is a major issue among patients, carers, and health professionals.

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4.     Young-Min Lee

On the day in which the module begins, Young-Min Lee was seen by a paediatrician in his rooms and was diagnosed with a urinary tract infection. Young-Min was sent with his Korean mother to the local hospital to be admitted for treatment. An error occurred in the administration of Gentamicin to the child, which is detected before it causes any harm. The module explores the communication that occurs within the healthcare team in detecting and correcting the problem, as well as the issues associated with communicating with a patient from a culturally and linguistically diverse background, and the correct procedures for open disclosure.

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Acknowledgment: Tracy Levett-Jones, Conor Gilligan (and Team) University of Newcastle. Funded by the Australian Learning and Teaching Council, Office for Learning and Teaching.

WIIMALI VIRTUAL COMMUNITY

Wiimali was designed to transform understandings of healthcare, and to challenge traditional views of culture and community. It provides insights into the interactions between peoples’ lived realties and their healthcare experiences. Two of the resources in Wiimali focus specifically on medication safety –Eileen Poole’s’ story and the Medication safety interactive learning experiences in Wiimali Hospital Ward 1.

1.     Eileen Poole’s story

Eileen Poole’s journey from her home to the GP and pharmacy, through to admission to hospital because of a medication error illustrates the importance of quality use of medicines, interprofessional communication and collaboration, person-centred care, and therapeutic communication. The series of digital stories takes place in three settings:

  • Eileen Poole’s home
  • GP Super Clinic
  • Wiimali Pharmacy
  • Wiimali Hospital

https://www.wiimali.com.au/meet-eileen-poole/

2.     Medication safety interactive learning experiences in Wiimali Hospital Ward 1.

This set of activities focus on safe medication administration for three Wiimali Hospital patients: Bill Peters, Margaret McDonald and George Franks. Students are provided with critical thinking activities and medication calculation exercises in relation to these patients.

https://qmp.newcastle.edu.au/perception5/open.php?session=2980405820884127&name=wiimaliWard&group=wesbite

Acknowledgment: Tracy Levett-Jones, University of Technology Sydney, and Jenny Day, formerly University of Newcastle.

SAFE ADMINISTRATION OF MEDICATIONS: MANAGING INTERRUPTIONS DURING MEDICATION ADMINISTRATION

Three systematic reviews have demonstrated that interruptions (externally initiated events e.g., question from patient, telephone call, infusion pump alarm that suspends or diverts attention) during medication administration seriously compromise patient safety. A recent Australian study reported that interruptions occurred in 53% of medication administrations and that the risk and severity of medication errors double when the number of interruptions increasing from 0 to 4

This video can be used to highlight the issues associated with medication interruptions and how to prevent and manage them.

Acknowledgment: Marie Johnson, Tracy Levett-Jones, Elizabeth Manias, Bronwyn Everett and Gabrielle Weidemann. Funded by NSW Health Nursing & Midwifery Strategy Reserve Initiative Funding (SWSLHD)

MEDICATION SAFETY: A PATIENT’S STORY

In this video Helen Haskell, the founder and president of Mothers against Medical Error, shares the story of her son, Lewis Blackman, and the factors that led to his death.

https://www.youtube.com/watch?v=CspIrlJ2bd4&t=51s

Acknowledgment: Presented at the ‘Improving Medication Safety through Effective Communication and Teamwork’ conference.

NPS MEDICINEWISE – CPD FOR NURSES

This website provides a range of evidence-based education resources for nurses about safe and quality use of medicines.

https://www.nps.org.au/cpd/professions/nurses

Acknowledgment: Lynn Weekes (and team). Funded by the Australian Government department of Health