Medication Safety Standard
Medication safety is the practice of ensuring that medicines are prescribed, dispensed, administered and monitored correctly to minimise the risk of harm to patients.
The Medication Safety Standard describes the systems and processes that are required to ensure safe and appropriate use of medicines.
Intention of this standard
The Medication Safety Standard aims to ensure that clinicians safely prescribe, dispense and administer appropriate medicines, and monitor medicine use. It also aims to ensure that consumers are informed about medicines and understand their own medicine needs and risks.
There are 15 actions in the Medication Safety Standard, and they are categorised by criteria and item. Each action has reflective questions and key tasks to help you understand and meet each action.
Clinical governance and quality improvement to support medication management
Organisation-wide systems are used to support and promote safety for procuring, supplying, storing, compounding, manufacturing, prescribing, dispensing, administering and monitoring the effects of medicines.
Integrating clinical governance
Action 4.01
Action 4.01 states:
Clinicians use the safety and quality systems from the Clinical Governance Standard when:
- Implementing policies and procedures for medication management
- Managing risks associated with medication management
- Identifying training requirements for medication management
Intent
Safety and quality systems support clinicians in the safe and effective use of medicines and reduce medicine-related risk.
Reflective questions
- How are the health service organisation’s safety and quality systems used to:
- ensure appropriate governance of medication management
- support development and implementation of policies and procedures for medication management
- identify and manage risks associated with medication management
- identify training requirements for medication management?
Key tasks
- Set up and implement governance structures for medication management.
- Develop and implement policies and procedures for medication management.
- Use organisation-wide risk management systems to identify, monitor, manage and review risks associated with medication management.
- Provide access to training on medication management based on the specific needs of the workforce, including medicine-related information and decision support tools.
Applying quality improvement systems
Action 4.02
Action 4.02 states
The health service organisation applies the quality improvement system from the Clinical Governance Standard when:
- Monitoring the effectiveness and performance of medication management
- Implementing strategies to improve medication management outcomes and associated processes
- Reporting on outcomes for medication management
Intent
Quality improvement systems are used to support effective medication management and reduce medicine-related risks.
Reflective questions
- How are the effectiveness and performance of medication management monitored and improved?
- How are the outcomes of improvement activities communicated to the governing body, the workforce, consumers and other organisations?
Key tasks
- Review, measure and assess the effectiveness and performance of medication management strategies and practices.
- Implement quality improvement strategies for medication management based on the outcomes of monitoring activities.
- Provide information on the outcomes of quality improvement activities to the governing body, workforce, consumers and other organisations.
Partnering with consumers
Action 4.03
Action 4.03 states
Clinicians use organisational processes from the Partnering with Consumers Standard in medication management to:
- Actively involve patients in their own care
- Meet the patient’s information needs
- Share decision-making
Intent
Clinicians partner with patients to minimise medicine-related risks.
Reflective questions
- What processes from the Partnering with Consumers Standard do clinicians use to involve patients in planning and making decisions about their medication management?
How does the health service organisation ensure that patients are provided with medicine-related information tailored to their needs and health literacy?
Key tasks
- Review strategies in the Partnering with Consumers Standard to inform the implementation of actions in the Medication Safety Standard.
- Provide information to patients about medication management tailored to their specific needs and level of health literacy.
Medicines scope of clinical practice
Action 4.04
Action 4.04 states
The health service organisation has processes to define and verify the scope of clinical practice for prescribing, dispensing and administering medicines for relevant clinicians
Intent
Clinicians work within their scope of clinical practice, and have the knowledge, skills, competence and delegated authority to safely manage, use and handle medicines.
Reflective questions
- What processes does the health service organisation use to ensure that only clinicians with the relevant authority prescribe, dispense or administer medicines?
What processes are used to ensure that clinicians are competent and operating within their individual scope of clinical practice?
Key tasks
- Identify all areas where specific authorisation is required to prescribe, dispense or administer medicines
- Use organisation-wide credentialing and scope of clinical practice processes to ensure that only authorised members of the workforce can prescribe, dispense or administer medicines
- Regularly assess qualifications, credentials and competence of the clinical workforce to safely prescribe, dispense and administer medicines.
Documentation of patient information
A patient’s best possible medication history is recorded when commencing an episode of care. The best possible medication history, and information relating to medicine allergies and adverse drug reactions are available to clinicians.
Medication reconciliation
Action 4.05
Action 4.05 states
Clinicians take a best possible medication history, which is documented in the healthcare record on presentation or as early as possible in the episode of care
Intent
Patients and carers are actively involved in taking a best possible medication history (BPMH) as the first step in the process of medication reconciliation.
Reflective questions
- What processes are used to obtain and record a BPMH in the patient’s healthcare record?
- How does the health service organisation evaluate the quality of patient involvement in the process of obtaining a BPMH?
Key tasks
Implement a systematic process for obtaining the patient's actual medicine use and recording a BPMH.
Action 4.06
Action 4.06 states
Clinicians review a patient’s current medication orders against their best possible medication history and the documented treatment plan, and reconcile any discrepancies on presentation and at transitions of care
Intent
A formal, structured, multidisciplinary and timely process is in place for reconciling medicines against the BPMH and treatment plan, which involves patients and carers.
Reflective questions
- What processes are in place to ensure that clinicians review their patients’ current medication orders against the BPMH?
- How and where are discrepancies with a patient’s medicines documented and reconciled?
- How are changes to a patient’s medicines, and the reasons for change, documented and communicated at transfer of care or on discharge?
Key tasks
- Implement a formal structured process to ensure that all patients admitted to the health service organisation receive accurate and timely medication reconciliation on admission, at transfer of care and on discharge.
Adverse drug reactions
Action 4.07
Action 4.07 states
The health service organisation has processes for documenting a patient’s history of medicine allergies and adverse drug reactions in the healthcare record on presentation
Intent
Medicine-related risks for patients are minimised by documenting and referring to the patient’s history of medicine allergies and adverse drug reactions (ADRs).
Reflective questions
- How does the health service organisation ensure that a patient’s history of medicine allergies and ADRs is recorded when taking a best possible medication history (BPMH) on presentation?
- How do clinicians who prescribe, dispense or administer medicines know that a patient has an existing medicine allergy or ADR?
Key tasks
- Document known patient medicine allergies and ADRs on presentation, and make this information available when clinicians prescribe, dispense and administer medicines.
Action 4.08
Action 4.08 states
The health service organisation has processes for documenting adverse drug reactions experienced by patients during an episode of care in the healthcare record and in the organisation-wide incident reporting system
Intent
Medicine allergies and ADRs experienced by patients while in the health service organisation are documented in the patient's medicine allergy/ADR history and in incident management and investigation systems.
Reflective questions
- What processes are used to ensure that all medicine allergies and ADRs experienced by a patient during an episode of care are recorded in the patient’s healthcare record, and reported in the incident management and investigation system?
- How do clinicians who prescribe, dispense or administer medicines know that a patient has experienced a new medicine allergy or ADR?
- What processes are used to ensure that clinicians document a patient’s new medicine allergies or ADRs on their medicines list?
Key tasks
- Document and report medicine allergies and ADRs experienced by patients during their episode of care (see Actions 4.01 and 4.02).
Action 4.09
Action 4.09 states
The health service organisation has processes for reporting adverse drug reactions experienced by patients to the Therapeutic Goods Administration, in accordance with its requirements
Intent
All new suspected ADRs experienced by patients during their episode of care are reported to the Therapeutic Goods Administration (TGA).
Reflective questions
- What processes are used to report all new suspected ADRs experienced by patients during their episode of care to the TGA?
- What resources, tools or information are provided to clinicians to encourage the reporting of ADRs?
How does the health service organisation use the information and reports on suspected ADRs experienced by its patients?
Key tasks
- Report all new suspected ADRs experienced by patients to the TGA.
Continuity of medication management
A patient’s medicines are reviewed, and information is provided to them about their medicines needs and risks. A medicines list is provided to the patient and the receiving clinician when handing over care.
Medication review
Action 4.10
Action 4.10 states
The health service organisation has processes:
- To perform medication reviews for patients, in line with evidence and best practice
- To prioritise medication reviews, based on a patient’s clinical needs and minimising the risk of medication-related problems
- That specify the requirements for documentation of medication reviews, including actions taken as a result
Intent
Medicines use is optimised and medicine-related problems are minimised by conducting medication reviews and documenting the outcomes in partnership with patients.
Reflective questions
- What evidence-based policies, procedures or guidelines for medication review are in place for clinicians?
- What processes are used to identify patients at risk of medicine-related problems or adverse events, and to set priorities for patients for medication review?
Key tasks
- Conduct evidence-based medication reviews on existing and newly prescribed medicines to optimise therapy for patients.
- Set up processes for:
- determining who is responsible at each point in the medication management pathway
- prioritising medication reviews for, and in partnership with, patients who are most at risk of a medicine-related problem
- documenting any recommendations and action taken as a result of a medication review
- identifying and monitoring trends in medicine-related problems, including those that have been prevented.
Information for patients
Action 4.11
Action 4.11 states
The health service organisation has processes to support clinicians to provide patients with information about their individual medicines needs and risks
Intent
Clinicians are supported to provide information to their patients about medicines options, benefits and risks.
Reflective questions
- How do clinicians inform patients about options for their care, including use of medicines?
- What information do clinicians provide to patients about the benefits and risks of medicine-related treatment options?
- How do clinicians gain access to medicine-related information for patients?
Key tasks
- Provide patients and carers with enough information about treatment options for them to make informed choices about their medicines, and to adhere to medicine-related treatment plans.
- Support clinicians to provide medicine-related information when treatment options are discussed and when treatment decisions have been made.
Provision of a medicines list
Action 4.12
Action 4.12 states
The health service organisation has processes to:
- Generate a current medicines list and the reasons for any changes
- Distribute the current medicines list to receiving clinicians at transitions of care
- Provide patients on discharge with a current medicines list and the reasons for any changes
Intent
Medicine-related problems and risk of patient harm are minimised by maintaining a current medicines list with reasons for any changes, and providing it in a suitable format for clinicians at transfer of care and patients on discharge.
Reflective questions
- What processes are used by clinicians to document and maintain a current medicines list during a patient’s episode of care?
- How do clinicians generate a current medicines list, including reasons for any changes, to use at clinical handover and provide on discharge?
Key tasks
- Implement processes that support clinicians to generate and maintain current medicines lists throughout an episode of care
- Incorporate the use of medicines lists into clinical handover procedures
- Implement a process to provide current medicines lists and the reasons for any changes to patients on discharge.
Medication management processes
Health service organisations procure medicines for safety. Clinicians are supported to supply, store, compound, manufacture, prescribe, dispense, administer, monitor and safely dispose of medicines.
Information and decision support tools for medicines
Action 4.13
Action 4.13 states
The health service organisation ensures that information and decision-support tools for medicines are available to clinicians
Intent
Medication management is supported by providing relevant, up-to-date and evidence-based medicine-related information and decision-support tools to the clinical workforce.
Reflective questions
- How does the health service organisation ensure that medicine-related information and decision support tools are up to date and available to clinicians at the point of decision-making?
Key tasks
- Maintain a variety of up-to-date and evidence-based medicine-related information and decision-support tools that assist clinicians with their responsibilities to provide safe and effective medication management.
- Make up-to-date and evidence-based medicine-related information and decision-support tools available to clinicians.
Safe and secure storage and distribution of medicines
Action 4.14
Action 4.14 states
The health service organisation complies with manufacturers’ directions, legislation, and jurisdictional requirements for the:
- Safe and secure storage and distribution of medicines
- Storage of temperature-sensitive medicines and cold chain management
- Disposal of unused, unwanted or expired medicines
Intent
Medicines are safely stored and distributed with minimal waste, and disposed of appropriately.
Reflective questions
- How does the health service organisation ensure that all medicines (including temperature-sensitive medicines) are stored and handled according to manufacturers’ directions?
- How does the health service organisation manage and report risks associated with the storage of medicines?
How does the health service organisation ensure that processes for medicines disposal are consistent with state or territory requirements and the manufacturer’s instructions?
Key tasks
- Identify risks associated with medicines handling, storage and distribution across the organisation, and develop and implement evidence-based strategies aimed at reducing these risks.
- Implement systems and equipment that continuously monitor and maintain the integrity of temperature-sensitive medicines.
- Implement policies, procedures and guidelines for the disposal of unused, unwanted or expired medicines.
High-risk medicines
Action 4.15
Action 4.15 states
The health service organisation:
- Identifies high-risk medicines used within the organisation
- Has a system to store, prescribe, dispense and administer high-risk medicines safely
Intent
Medicine-related risks are minimised by identifying and safely managing processes relating to high-risk medicines.
Reflective questions
- What processes are in place to identify medicines that are considered to be high risk?
How does the organisation ensure safe and appropriate storage, prescribing, administration and distribution practices for high-risk medicines?
Key tasks
- Regularly assess the use and misuse of high-risk medicines, relating to storage, prescribing, dispensing and administration.
- Develop and implement evidence-based risk-reduction strategies for high-risk medicines.