National safety and quality health service standards

Standard 4
Medication Safety 
Standard 5
Patient Identification            
Standard 6
Clinical Handover                  
Medication safety, patient identification and clinical handover

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This is the second article by the Australian Commission on Safety and Quality in Health Care (the Commission), in a series describing the National Safety and Quality Health Service (NSQHS) Standards. In this edition NSQHS’s Amy Winter outlines the purpose and benefits of the following three Standards:

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Many health service organisations will already have strategies and systems in place which address these areas. The purpose of the NSQHS Standards is not to replace good systems, but to set out minimum standards for safety and quality,and provide quality assurance guidelines and improvement mechanisms to achieve them.
Each of the Standards has been developed by the Commission in collaboration with technical experts,Each of the Standards has been developed by the Commission in collaboration with technical experts, appropriate and relevant for clinical settings.

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Standard 4. Medication Safety
Standard 5. Patient Identification
Standard 6. Clinical Handover

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More information
More information and resources to support implementation of the NSQHS Standards are available on the Commission’s web site at www.safetyandquality.gov.au or by contacting the  Commission’s Advice Centre on 1800 304 056 or accreditation@safetyandquality.gov.au.
Standard 4

Medication Safety

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Medicines are the most common treatment used in health care1. Because they are so commonly used, medicines are associated with a higher number of reported errors and adverse events than most other aspects of health care¹.
Over 1.5 million Australians are estimated to experience an adverse event from medicines each year1.These events are often costly in terms of patient harm, morbidity and mortality, and can be a  drain on already stretched health care resources. Many are avoidable.
The key to reducing the prevalence of avoidable adverse medication incidents is addressing the areas where there is a known risk of error. For example, we know that there is higher risk of harm occuring when:

• processes for prescribing, dispensing, administering and monitoring medicines are not standardised
  


• there is incomplete medication information during transition of care


• medicines look or sound similar to other medicines


• medicines are poorly labeled or not labeled at all , and


• high risk medicines are practiced poorly.

Standard 4 describes the elements of a safe medication management system.
The intention is to ensure competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and carers.
The Standard sets out a framework for health services to reduce the risk of common medication errors. Strategies and systems for improving the safety and quality of medicine should be in place, including:

• standardised processes and systems


• improved communication between clinicians and between patients and clinicians


• the use of technology to support information recording and transfer, and


• access to patient information and clinical decision support at the point of care.

To meet the criteria for Standard 4, health service organisations must be able to demonstrate that:

• effective clinical governance frameworks, policies and systems for medication safety have been established.


• the clinical workforce accurately records full medication history upon presentation or as early as possible in the episode of care, and is available throughout the duration of care.


• information is available and decision support tools and processes are in place to support clinicians in safely prescribing, dispensing, administering, storing, manufacturing, compounding and monitoring the use of medicines.


• clinicians provide a complete list of a patient’s medicines to receiving clinicians and to patients when handing over care or changing medicines.


•  patients are informed about medication treatment options,benefits and risks, and medication plans are developed in partnership with patients.

For more information about Standard 4: Medication Safety,and the work of the Commission in this area, visit www.safetyandquality.gov.au/our-work/medication-safety
Standard 5                                   
Patient Identification and Procedure Matching

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Patient identification and the matching of a patient to an intended treatment is an activity that is performed routinely in all care settings. Risks to patient safety occur when there is a mismatch between a patient and components of their care,whether those components are diagnostic, therapeutic or a mismatch between a patient and components of their care, whether those components are diagnostic, therapeutic or supportive.
Throughout health care, the failure to correctly identify patients and match that information to an intended treatment continues to result in wrong person, wrong site procedures, medication errors, transfusion errors and diagnostic testing errors.
Much of the information about the occurrence of patient mismatching comes from incident reporting systems.In 2009-2010 there we 10 reported events in Australia where procedures involving the wrong patient or body part resulted in a death or major permanent loss of function2. When taking into account less serious events from nonsurgical areas such as pathology and  radiology, the number of mismatched events rises considerably¹.
The Commission’s work focuses on the standardisation of processes and development of safety routines for the common tasks needed for patient identification. These routines safeguard patients and allow the workforce to focus their attention the provision of clinical care.
Standard 5: Patient Identification and Procedure Matching addresses the need for standardised patient identification processes. Through its implementation, systems will be established that ensure correct identification of patients and correct matching of patients with their intended treatment.
To meet the criteria for Standard 5, health service organisations must be able to demonstrate that:

• at least three approved patient identifiers are used to identify patients when providing care, therapy or services.


• patient identity is confirmed using three approved identifiers when transferring responsibility for care.


• explicit processes are in place to match patients and their intended care.

For more information about Standard 5: Patient Identification and Procedure Matching including specifications for a Standard Patient Identification Band, FAQ’s and fact sheets, visit www.safetyandquality.gov.au/our-work/patient-identification

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Standard 6                                                                       
Clinical Handover

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Clinical handover is the transfer of professional responsibility and accountability for some or all aspects of care for a patient or group of patients, to another person or professional group for a patient on a temporary or permanent basis^3-4.
Effective clinical handover can reduce communication errors between health professionals and improve patient safety and care.
Breakdown in the transfer of information has been identified as one of the most important contributing factors in serious adverse events and is a major cause of preventable patient harm⁵.
Poor or absent handovers, or failure to transfer responsibility and accountability can result in delays in diagnosis or treatment, tests being missed or duplicated which can lead to the wrong treatment or medication being administered to the wrong patient⁶.
Current handover processes are highly variable and may be unreliable, causing clinical handover to be a high risk area for patient safety. Standard 6: Clinical Handover addresses the need for effective structured communication during clinical handover. The intention of this Standard is to ensure there is timely, relevant and structured clinical handover that supports safe patient care.
To meet the criteria for Standard 6, health service organisations must be able to demonstrate that:

• a governance structure and leadership model to implement effective clinical handover systems is in place.


• documented and structured clinical handover processes are in place.


• mechanisms to include patients and carers in clinical handover processes have been established.

Clinical handover solutions must be fit-for-purpose and appropriate to the clinical context in which hand over occurs.
When a standard process for clinical handover is used, the safety of patient care will improve as critical information is more likely to be transferred and acted upon. ^7-10
The Commission has developed a range of resources to assist health service organisations to implement Standard 6 including The OSSIE Guide to Clinical Handover,the Implementation Toolkit  or Clinical Handover and the Electronic Resource Portal for Clinical Handover Improvement.
To download these and other clinical handover resources, visit  www.safetyandquality.gov.au/our-work/clinicalcommunications/clinical-handover

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More Information 
Information and resources to support implementation of the NSQHS Standards is available on the Commission’s web site at www.safetyandquality.gov.au or by contacting the Commission’s  Advice Centre on 1800 304 056 or accreditation@safetyandquality.gov.au
An advice Centre has also been established to provide information An advice Centre has also been established to provide information surveyors during surveys is available.
This service can be accessed by surveyors during surveys is available. This service can be accessed by telephone within Australia on 1800 304 056, or via email on accreditation@safetyandquality.gove.au
References
1. Australian Commission on Safety and Quality in Health Care. Windows into safety and quality in health care 2008. Sydney: Australian Commission on Safety and Quality in Health Care, 2008.
2. Australian Commission on Safety and Quality in Health Care. Windows into safety and quality in health care 2011. Sydney: Australian Commission on Safety and Quality in Health Care, 2011.
3. National Patient Safety Agency. Seven steps to patient safety. London: National Patient Safety Agency, 2004.
4. Australian Medical Association. Safe handover : safe patients, 2006.
5. Wong MC, Yee KC, Turner P. Clinical Handover Literature Review. eHealth Services Research Group, University of Tasmania, 2008:115.
6. Australian Commission on Safety and Quality in Health Care. The OSSIE Guide to clinical handover improvement Sydney. Australian Commission on Safety and Quality in Health Care, 2009.
7. Aldrich R, Duggan A, Lane K, Nair K, Hill K. ISBAR revisited: identifying and solving barriers to effective clinical handover in inter-hospital transfer - public report on pilot study. In: Health HNE, editor. Newcastle, 2009.
8. Clark E, Squire S, Heyme A, Mickle M, Petrie E. The PACT Project: improving communication at handover. Medical Journal of Australia 2009;190(11):S125-S127.
9. Hatten-Masterson SJ, Griffiths ML. SHARED maternity care: enhancing clinical communication in a private maternity hospital setting. Med J Aust 2009;190(11 Suppl):S150-S151.
10. Wong MC, Yee KC, Turner P. Nursing and medical handover in general surgery, emergency medicine and general medicine at the Royal Hobart Hospital - public report on pilot study. In: Tasmania Uo, editor. Hobart, 2008.