In 2018, the Commission identified a need to develop guidance for the safe selection and storage of medicines, with a focus on look-alike, sound-alike (LASA) medicines. Medication incidents related to LASA medicine names are one of the most common type of medication error.
Over recent years, concerns have also been raised regarding the risk of selection errors due to the increasing availability of generic medicines and the similarities in medicine labelling and packaging.
This guidance in the form of a set of principles and risk-reduction strategies aims to address all aspects of medicine selection and storage that can affect the likelihood of medication error, including:
- Human factors (system design and behaviours that can impact safety)
- Labelling (for example, font size for shelf labels)
- Organising medicines (for instance, lack of order or system)
- Storage of multiple strengths
- Storage of medicines with LASA names
- Storage of medicines with similar packaging
- Formulary decisions and procurement.
The Commission supports a multi-faceted approach to help clinicians reduce the risk of selection errors from medicines and encourages health service organisations (HSOs) to use this guidance to consider all options when implementing risk-reduction strategies. Lower leverage solutions may be used at first. However, these will often need to be supplemented by other strategies that focus on system as well as human factor issues to improve medication safety.
Principles for the safe selection and storage of medicines
This guidance comprises:
The Principles for safe selection and storage of medicines has been developed to address safe selection and storage of all medicines, including LASA medicines, which have additional considerations given their greater potential for confusion.
The principles are broad and closely aligned with the NSQHS Standards with particular reference to the Clinical Governance Standard and the Partnering with Consumers Standard. They also consider the impact of a clinician’s work environment.
Strategies proven to improve medication safety at selection include a mix of high leverage and low leverage strategies, including:
- Tall Man lettering of LASA name pairs
- Physical separation of different brands or strengths of medicines
- Special shelf signage
- Technology solutions
- Procurement/formulary strategies
- Audits and medication safety walk rounds.
The guidance includes:
- Two overarching organisation-wide Principles:
- Consumer participation
- An additional 14 principles supported by a total of 91 risk reduction strategies
- Practical examples to assist HSOs when assessing their medicine selection and storage risks.
It is accompanied by a survey tool.
Survey tool for the safe selection and storage of medicines
During 2019, the Commission developed and tested a survey tool based on an initial set of 17 principles for the safe selection and storage of medicines.
The survey tool was piloted using SurveyMonkey™ over a four-week period commencing 23 April until 20 May 2019.
Survey responses were received from every state and territory along with a mix of public and private, large metropolitan and small regional hospitals. A mix of clinical areas were selected by organisations.
The pilot supported the usefulness of the set of principles, accompanying risk reduction strategies and survey tool in assessing hospitals’ medicine selection and storage risks.
The survey tool contains a set of 14 principles supported by 91 risk reduction strategies. It also contains:
- Numerous practical examples to assist HSOs when assessing their medicine selection and storage risks
- An action plan section for HSOs to complete and for their medicines’ governance group to monitor.