Background
The Safety and Quality Council has developed a national alert system for high risk medications. The aim of this national communication strategy is:- to warn health leaders and professionals about serious known medication hazards
- to provide tools to effectively ensure action to reduce the hazards
- to set out responsibilities for system change.
The Safety and Quality Council gratefully acknowledges the contribution of many groups who have worked together to contribute to the content of this alert, as well as its wide dissemination to all public and private hospitals and health care professionals. This partnership approach is recognized as being fundamental to achieving improvements in the safety of our health system. Long term actions will be required to implement systems to overcome known medication hazards, and to regularly review and evaluate those systems.
Concentrated intravenous potassium chloride (KCL) is the subject for the first alert. This has been implicated in fatalities in Australia and overseas. Many hospitals have already taken the first steps to remove this substance from general patient care areas and this needs to be taken up on a consistent, national basis.
Medication Alert
Read on... Medication Alert 1 - POTASSIUM CHLORIDE, INTRAVENOUS, October 2003 (PDF 207 KB)Change Management Case Studies - POTASSIUM CHLORIDE, INTRAVENOUS
Several facilities have commenced implementation of actions recommended in the Alert. Two major teaching hospitals have kindly agreed to share with others their learning experiences of how they went about changing their systems. These change management case studies address:
- Why potassium was selected?
- Who "drove" the initiative and who was involved?
- What communication was undertaken?
- What barriers were encountered and how were they overcome?
- What were the short term "wins"?
- What still needs to be done?
Similar change management case studies are invited from others. In particular, sharing of information from different settings eg. private hospitals, rural hospitals, day care or aged care facilities would greatly assist progress in those settings.
- Change Management Case Study from Royal Adelaide Hospital, South Australia (PDF 118 KB)
(This includes example flyers for nursing and medical staff and education session topics).
Updated amended version 1 December, 2003. - Change Management Case Study from Austin Health, Victoria (PDF 28 KB)
Other tools
Facilities that have embarked on changes to their system have developed many other tools eg. new policy and procedure documents, treatment guidelines, wall flyers and other materials. Again, two major teaching hospitals have kindly agreed to share some of their tools. Similar examples are invited from others, again especially from different settings eg. private hospitals, rural hospitals, day care or aged care facilities to assist progress in those settings.- Potassium Guidelines (Adult) Prescribing and Administration from Royal Hobart Hospital, Tasmania (PDF 78 KB)
- Policy and Administration of Intravenous Potassium Chloride from The Alfred Hospital, Victoria (PDF 226 KB)
(This includes example flyers for wards, prescribers and alert stickers).
Updated version amended 3 November, 2003.
Acknowledgment of stakeholder involvement
The Australian Council for Safety and Quality in Health Care wish to thank the following organisations and government agencies for their input and/or dissemination of this alert notice:ACHSE - Australian College of Health Service Executives
ADRAC - Adverse Drug Reactions Advisory Committee
ADSA - Australasian Day Surgery Association
AHA - Australian Healthcare Association
AIMS - Australian Incident Monitoring System
AMA - Australian Medical Association
ANF - Australian Nursing Federation
APHA - Australian Private Hospitals Association
CHA - Catholic Health Australia
CHF - Consumers' Health Forum
Australian DoHA - Australian Department of Health and Ageing
HPCA - Health Professionals Council of Australia
Medicines Australia
MUNCCI - Monash University National Centre for Coronial Information
NPS - National Prescribing Service
NSWTAG - NSW Therapeutic Assessment Group Inc
NTD&TC - Northern Territory Drug and Therapeutics Committee
PGA - Pharmacy Guild of Australia
PHIQS - Private Health Industry Quality and Safety Committee
PSA - Pharmaceutical Society of Australia
QHDAC - Queensland Hospitals Drug Advisory Committee
RACMA - Royal Australian College of Medical Administrators
RACP - The Royal Australian College of Physicians
RACS - Royal Australian College of Surgeons
RCNA - Royal College of Nursing Australia
SATAG - South Australian Therapeutic Advisory Group
SHPA - Society of Hospital Pharmacists of Australia
SQOF - State Quality Officials Forum
TSTDC - Tasmanian Statewide Therapeutic Drug Committee
VicTAG - Victorian Therapeutics Advisory Group
WADTC - Western Australian Drugs and Therapeutics Committee
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