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EAG-Minutes-10-Nov-11

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					 Minutes of Medication Safety Expert Advisory Group Meeting
                Thursday 10 November 2011 9.30am to 15.30pm
      Karaka Room, Ministry of Health, Unisys House, 650 Great South Road,
                                 Penrose, Auckland

Attendees
Dwayne Crombie (Chair)                 Steven Lillis (GP, NZCGP)
Mary Seddon (CMDHB)                    David Woods (NZF)
Nirasha Parsotam (HQSC)                Alan Davis (NDHB)
Janet Mackay (PHARMAC)                 Sandra Fielding (BoPDHB)
Beryl Wilkinson (Consumer)             Stacey Hurrell (Waitemata DHB)
Avril Lee (Waitemata DHB)              Mary-Anne O’Rourke (Kowhai Health)
Rob Ticehurst (ADHB)

In Attendance: Gillian Bohm (HQSC), Beth Loe (HQSC), Carmela Petagna (HQSC)

Apologies : Chris Cameron (CCDHB)

Minutes
Item    Agenda          Notes/comments                                        Action Required
 1.     a. Member           The chair welcomed people to the meeting
        introductions        and attendees introduced themselves
                             giving a brief resume
        b. EAG              Members were asked to indicate any                    Members to send in
        disclosure of        potential conflicts of interest that may arise         conflict of interest
        interests            for either themselves or through their                 register (All)
                             immediate family                                      Update conflict of
                                                                                    interest register (Beth)
        c. EAG TOR          The TOR for the governance group and the              Circulate TOR (Beth)
                             steering group were requested
                            The medication safety governance group,
                             steering group, members and individual
                             clinicians could suggest projects to the
                             EAG
                            There is provision in the TOR for the chairs
                             of the governance, expert advisory and
                             steering group to attend meetings of each
                             group
                            It was agreed that the strategic agenda
                             items should come before the technical
                             agenda items and that there did need to be
                             a balance between the strategic and
                             operational work
                            Prioritisation of the operational work would
                             be necessary going forward
        d. EAG 2012         Proposed meeting dates for 2012 had                   Inform Beth if meeting
        meeting dates        been circulated with the agenda: 9 Feb, 19           dates all unsuitable (All)
                             April, 14 June, 16 Aug, 11 Oct, 6 Dec
                            The dates will be confirmed when the draft
                             minutes are circulated




                                              1
     e. Medication      Gillian gave a brief overview on the role of        Discussion between
     safety              the HQSC and the history behind its                  chairs of the 3 groups
     governance          genesis                                              (EAG, Steering group &
     structure          The roles of the governance and steering             NICLG) (Dwayne)
                         groups and NICLG were highlighted                   Update flow diagram
                        There was a clear need to integrate the              (Nirasha)
                         work of the steering group, the EAG and
                         NICLG
                        It was agreed that the structure diagram
                         needed to more accurately reflect the two-
                         way flow of information and work
2.   a, b & c.          The medication safety programme update,
     Medication          scorecard and status update presented to
     safety              the board were provided for information
     programme          There was discussion regarding possible
     update,             prioritisation tools that could be used for
     balanced            medicines reconciliation
     scorecard &        CMDHB have a tool based on the
     status update       electronic information gathered from their
                         PMS and automated dispensing cabinet
                         information
                        This would not be transferable to all DHBs
                         e.g. only 4 DHBs have automated
                         dispensing cabinets and not all DHBs
                         operate the same PMS
                        No evaluation has been carried out on the
                         electronic tool yet but it is planned that
                         NIHI will conduct an evaluation
                        The internationally agreed goal is that
                         medicines reconciliation is carried out for
                         all patients
                        Currently all DHBs are using different
                         prioritisation methods
                        The Commission is reviewing the
                         prioritisation tools being used currently and
                         whether a simple tool that all DHBs could
                         adopt can be developed and piloted
     d. National        The paper on the NMC long stay version              Small corrections to the
     Medication          was discussed                                        design to be
     Chart              There was discussion about evaluation                communicated to the
                         and cost benefit analysis of the NMC                 printer (Beth)
                        Australia had carried out an observational          Consult with paediatric
                         study and considered that there was a                clinicians on design of
                         17% error reduction since their NMC was              paediatric friendly chart
                         introduced                                           (Beth)
                        The proof of the proposed long stay chart           Feedback to informal
                         was circulated for comment                           change requests made
                        It was agreed that the current design with           by clinicians (Beth)
                         small corrections would be piloted
                        It was agreed that the risks identified at the
                         design sub-committee meeting had been
                         mitigated in the proposed design
                        It was agreed that the design would be
                         piloted in the four volunteer DHBs
                        The proposal to include paediatric clinical
                         requirements within the design of the NMC
                         was discussed
                        It was agreed that paediatric clinicians
                         would be consulted regarding the


                                          2
                      proposed paediatric additions
                     There was a proposal that a day stay chart
                      was required – this would include the
                      current front page and once only page
                     Should the long stay pilot be successful
                      and it is agreed that there should be one
                      chart to cover acute and long stay then a
                      proposal for a day stay chart would be
                      considered
                     There needed to be some feedback to
                      clinicians about the change requests
                      already submitted for the NMC
                     There was discussion about submitting
                      requests through the electronic change
                      register
                     The Commission was scoping a piece of
                      work to address the design and
                      implementation of a medication chart
                      appropriate for use in aged residential
                      care. Once scoped this project would e
                      tendered to the market.
e. Medicine          The prioritisation tool for MR was
reconciliation        discussed under 2a,b&c
(MR)                 MR health target (health target e.g. 6 hour
                      wait in ED) was proposed to the Minister
                      but is not proceeding in the 2012/2013
                      year but remains a possibility

f. eMedicines        There was a discussion around the cost           Distribute business
programme -           benefit analysis. The associated business         case for e medicines
electronic            case had not been provided and was                programme after
prescribing and       requested by members                              meeting on 18.11.11
administration       The Commission is responsible for the             (Beth)
(ePA) and             paper based projects and in the transition       Agenda item at the next
electronic MR         phase of the Commission’s establishment           meeting - review the
(eMR)                 had signalled a commitment to the next            “electronic direction” for
                      phase of the eMedicines programme.                medicines safety
                     It partners with the NHB and NHITB in the         (Beth)
                      electronic projects and requested a
                      business case be developed before the
                      funding for the project could be released
                     The Commission has agreed a financial
                      contribution for the next phase of the
                      eMedicines Programme but requires some
                      further enhancements to be made to the
                      cost benefit analysis
                     The long term vision through “a Go For
                      Gold” campaign is that by 2014 all DHBs
                      will have introduced eMedicine
                      Management solutions, specifically ePA
                      and eMR
                     There was a discussion around vendor
                      engagement and selection. The original
                      intention under SMM was for multiple
                      vendors but there is now a single vendor
                      for each part of the programme. This does
                      not limit a DHB from engaging with another
                      vendor as long as inter-operability with
                      other systems is maintained
                     The original SMM project called for e point

                                      3
                          of care i.e. prescription, medicine, patient
                          linked electronically
                         The Commission is looking to appoint a
                          dedicated clinical resource to manage the
                          eMedicines implementation
                         A workshop is planned for 18.11.11 to
                          further strengthen the cost benefit analysis
                         There was discussion about standards for
                          vendors
3.   Prioritisation      A paper was circulated identifying seven          Visualisation of the
     of EAG work          possible long term goals and four defining         patient journey and
                          categories (used by the VA in USA) that            possible harm points to
                          could be used as a basis for prioritisation        be circulated (Beth)
                         It was agreed that these were more                Develop a potential
                          principals rather than goals                       prioritisation framework
                         Another possible framework was to use              (Nirasha)
                          the organisationally based goals from
                          “Building a Safer NHS”
                         There was a broad discussion about
                          measuring and evaluation within the
                          Commission but also the need to
                          incorporate measuring and evaluation into
                          EAG work
                         Each project should consider harm
                          minimisation and a reduction in adverse
                          effects. The ADE trigger tool is the only
                          available measure of harm
                         Consider the medication journey and what
                          can be done to reduce risk at points where
                          harm can occur, look at both the SQM and
                          the Australian journey (if one is available)
                         A simple cost benefit analysis that includes
                          the opportunity costs, the proposed action
                          and the proposed benefit could be used as
                          the basis for agreeing priorities

                      Individual member priorities
                       Situational awareness of where things are
                          at in terms of medication safety
                       Identify strategic direction for medication
                          safety in New Zealand
                       Unification and less duplication of effort
                       Stop measuring and increase
                          implementation of effort
                       Spreading knowledge and effort
                       Empower patients to challenge
                       Educate, inform and engage everyone with
                          patient safety
                       Have the whole country on board
                       A clear structure and very transparent at
                          the grass roots level as to what is
                          happening
                       Prioritising patient and health professional
                          safety
                       Consumer safety and the right of the
                          consumer to refuse medication but when a
                          consumer is unable to participate in that
                          decision they will be safe. The need for
                          health professionals to be given education
                          whenever new medicines are marketed

                                          4
                      Ensure the quality of prescribing and
                       empower the consumer




4.   National         There was discussion about how the SQM
     Medication        strategy fits with “Actioning Medicines New
     Safety            Zealand”
     Strategy         There would need to be discussions with
                       the MoH regarding how the two strategies
                       could be joined
                      It was agreed that nothing should be done
                       for a year while the direction and priorities
                       are developed and set and then the
                       situation would be reviewed
5.   Safer            The three papers included on the agenda            Papers on medication
     Prescribing       were discussed                                      errors relating to
                      It was agreed that training on safer                hospital discharge
                       prescribing would be most appropriate as            prescriptions and
                       a core part of the curriculum at the intern         spikes when new
                       level                                               graduates start to be
                      The Medical Council and Health Workforce            circulated (Beth)
                       NZ should be made aware that there is a            Write to Medical
                       need for safer prescribing training and that        Council and Health
                       training on the national Medication Chart           Workforce New
                       should be introduced                                Zealand (Beth)
                      A question was raised about the evidence
                       available that training was needed and
                       mention was made of the studies done on
                       hospital discharge prescriptions and the
                       spikes in medication errors when new
                       graduates start




                                       5
6.   Medicine            This was discussed under item 5                     Feedback to Patients
     Reconciliation      It was agreed that at the present time there         First (Carmela)
     in Primary           were many systems in place and not all
     Care                 hospitals or primary care services were at
                          the same level of information provision
                         The principal feedback was that there were
                          issues with the generalisability of the data
                          because the work had been carried out in
                          one region

7.   Health              The patient pamphlet wasn’t discussed               Communicate the three
     Literacy and        The medicine reconciliation pamphlets that           classes of medicines to
     Consumer             had recently been published and were                 health literacy staff
     Engagement           available to download off the Commission             (Beth)
                          website were mentioned                              Agenda patient
                         The original scope given to NZ Guidelines            pamphlet at next
                          Group for the Health Literacy report was             meeting (Beth)
                          unknown (unfortunately Gillian had to
                          leave the meeting before this item)
                         Because the scope was unknown only the
                          recommendation that requested
                          information from the EAG was discussed
                         It was agreed, after some discussion, that
                          the three classes of medicines for which
                          significant safety issues arise that should
                          be targeted for health literacy improvement
                          are: over the counter analgesics (e.g.
                          paracetamol, ibuprofen and other
                          NSAIDs), anticoagulants, gout medication
                         There is a need for broader support on
                          building the consumer voice
8.   Labelling and       There was a discussion based on the                 Recommended
     packaging            request from the chair of the NZULM                  concentration wording
                          regarding the use of Tall Man lettering              for labelling standards
                         The general consensus was that an                    (Rob)
                          agreed list of medicine names with tall             Discuss labelling and
                          Man lettering would be useful in electronic          packaging issues with
                          systems where picking from a drop down               Medsafe (to include
                          menu was a source of error                           barcoding,
                         There had been a recent case where                   standardisation of
                          penicillamine had been chosen rather than            displaying
                          penicillin from a drop down list                     concentration)
                         Both Australia and Spain had recently                (Dwayne)
                          developed their own Tall Man lettering lists        Circulate the papers
                         Both countries based their lists on                  referenced in the
                          international lists, e.g. ISMP but had               Australian guidelines
                          developed the country specific list in very          that relate to evaluation
                          different ways                                       (Nirasha)
                         The Australian evaluation work was                  Follow up any further
                          discussed and it was agreed to contact the           evaluation undertaken
                          Australian Commission regarding any                  by the Australian
                          unpublished evaluation                               Commission (Beth)
                         Some of the papers regarding evaluation
                          referenced in the Australian documents
                          would be circulated
                         There was a discussion on the absence of
                          a definite date for the introduction of
                          barcoding in the recently published
                          labelling guidelines and it was felt that this
                          should be raised at a high level

                                           6
                          The NZULM identified that there are issues
                           with some manufacturers regarding
                           standard wording particularly for
                           concentrations and that non-standard
                           wording increases the risk of medication
                           error because the concentration can be
                           misinterpreted and the wrong dose given
9.    Measuring           An evaluation frame work for the paper
      and reporting        based chart and MR pilots and the ePA
                           pilot had been developed based on the IHI
                           principals and the PDSA cycle
                          This framework needed to be strengthened
                           going forward and the Commission had
                           asked for expressions of interest from
                           providers to work with the Commission on
                           measuring and evaluation for the
                           medication safety programme
                          6 provider profiles have been submitted
                           and a group will review the profiles and
                           make a shortlist. Those groups will be
                           asked to present before a final decision is
                           made. This selection process is a joint
                           decision between the Commission and the
                           NHIT Board
                          There was a brief discussion on evaluation
                           of the long stay chart in the forthcoming
                           pilots and it was agreed that the prime
                           evaluation was that it was fit for purpose
                           and that it reduces harm
                          Evaluating a reduction in harm as
                           discussed previously is hard to do with
                           current available methodology

Technical Agenda

10.   Implementation      The proposed process developed by SQM
      process for          Group was discussed
      alerts              It was agreed that this should be
                           implemented
11.   Heparin alert       The alert had been issued with the               Remind DHBs
                           accompanying action plan in September             regarding action plans
                           2011                                              (Beth)
                          Three DHBs had returned interim action           Review action plans in
                           plans                                             March 2012 (Beth)
12.   Caffeine alert      The alert was issued in October 2011
13.   Dabigatran          There was a discussion about comparing           Review of adverse drug
                           the number of adverse drug reaction               reaction reports against
                           reports received by CARM to that                  prescription numbers
                           anticipated from the clinical trial data          for the first three
                          The data for the number of prescriptions          months of dabigatran
                           as the denominator for the three month            usage
                           period July-October would be available           Send proposal to
                           from PHARMAC in January 2012                      PHARMAC that safety
                          The CARM adverse reaction data for the            considerations be taken
                           same three month period was available             into account when
                          The latest alert issued by Boehringer             proposals to fund high
                           Ingelheim through the European Medicines          risk medicines are
                           Agency and the UK Medicines and                   considered by PTAC
                           Healthcare products Regulatory Agency             (Beth)
                           was shared, this was based on cases of           Develop PIL for

                                          7
                            fatal bleeding in Japan                           dabigatran (Medication
                           The lessons that can be learned from what         Safety team)
                            happened following the funding of
                            dabigatran need to be identified to prevent
                            a similar occurrence
                           One lesson is that there needs to be pro-
                            active communication so that change
                            management and education for both health
                            professionals and consumers are available
                            earlier than happened with dabigatran
                           PHARMAC pointed out that funding
                            decisions for medicines often happen very
                            quickly
                           It was agreed that a process for managing
                            the approval and funding for high risk
                            medicines onto the market is needed
                           It was agreed that a proposal be made to
                            PHARMAC that identifying possible safety
                            issues that may result from any
                            internationally recognised high risk
                            medicine implementation should be
                            included in PTAC considerations
                           There was a discussion about the
                            information that had been available to
                            consumers on dabigatran when it was
                            funded: the package information leaflet
                            and the information in any direct to
                            consumer advertising
                           It was agreed that a consumer friendly
                            patient information leaflet would have been
                            helpful and one would be developed in
                            conjunction with the health literacy team
                           It was agreed that there would be no
                            benefit in developing a second dabigtatran
                            alert at this time
14.   Oral                 This was not discussed
      methotrexate
15.   Renal Drug           This was not discussed                           Update alert
      Dosing               Individual members gave some written              appropriately (Beth)
                            feedback
16.   Paediatric           This was not discussed                        
      weight based
      dosing
17.   Transdermal          This was not discussed                        
      patch alert          Members provided written feedback
18.   Hearing loss         The paediatric oncology centres in            
      associated with       Auckland and Christchurch both follow the
      cisplatin and         guidelines in the paediatric protocols
      gentamicin            regarding audiology testing and the testing
                            is carried out by the audiology service at
                            the two centres
                           A degree of hearing loss is expected but
                            all possible precautions are taken to
                            prevent it e.g. dose modification, no
                            treatment with other ototoxic agents
                           It has been identified that the normal
                            ototoxicity of aging is accelerated by
                            cisplatin treatment
                           It was agreed that no further action was
                            required and that the proposed gentamicin

                                            8
                             alert would not to be developed
19.   Clozapine             The coroner’s report was discussed                Reply to CCDHB
      related               The comments raised by CCDHB                       regarding development
      cardiomyopathy         regarding the recommended Waitemata                of national best practice
      and actions            DHB guidelines were discussed                      guidelines (Beth)
      arising from          It was agreed that national clozapine best        Write to Chief Coroner
      coroner’s report       practice guidelines should be agreed               regarding the
                             between the DHB mental health services             development of
                            It was agreed that the Chief Coroner               national guidelines
                             should be notified that where the                  (Beth)
                             development of national guidelines was felt
                             to be appropriate the Commission was not
                             always the appropriate body to oversee
                             their development
20.   Methoxyflurane        This had been added to the agenda                 Contact ambulance
      use in NZ              through the Commission chair and had               service Chief Medical
      ambulance              been raised by the ANZCA                           Officer regarding the
      service               It was unclear exactly what was expected           protocol that is used for
                             of the EAG                                         methoxyflurane (Beth)
                            Many of the references in the supplied
                             background document related to malignant
                             hypothermia which is a recognised
                             adverse reaction when methoxyflurane is
                             used as a general anaesthetic but does
                             not occur when it is used as an analgesic
                             (ambulance use is as an analgesic)
                            There are some references on trials
                             carried out in the Australian ambulance
                             service that are not included in the
                             information from the ANZCA
                            It was agreed that the Chief Medical
                             Officer for the ambulance service would be
                             contacted as to whether a protocol for the
                             use of methoxyflurane existed and if any
                             issues had been identified
21.   Paracetamol           The articles for Kaitiaki and the Best            Update both articles
      induced liver          Practice needed modification and would be          (Beth)
      damage                 discussed at the next meeting
      requiring liver
      transplants in
      children
22.   Look alike            These would be highlighted when
      sound alike            necessary going forward
      issues
23.   Allergy alert         This was an ongoing issue and the MoH
      system and             was working on a new NHI platform
      education             It was important to ensure the functionality
                             could be seen in both primary and
                             secondary care
      High risk             Of the internationally recognised high risk       Include insulin for
      medicines for          medicines no alert had been developed for          discussion on the next
      which no alert         insulin                                            agenda (Beth)
      had been              Two possible education modules for health
      developed              professionals were available
      Relationship          It was commented that it was important to         Invite both the NZPhVC
      with NZPhVC            maintain the links SQM Group had with              and ACC to the
      and ACC                both these organisations and in particular         February meeting
                             NZPhVC because of their current project            (Beth)
                             looking at medication error reports from
                             primary care

                                             9
                   It was agreed that the relationship between
                    the EAG and both organisations would be
                    maintained
Standards for      It was commented that the proposal to             Who, if anyone, is
primary care        develop standards for practice                     considering standards
practice            management systems made by Patients                for PM systems
management          First should be investigated further as this       (Nirasha)
(PM) systems        may add value
                   It was felt that other organisations may
                    already be working on this




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