Minutes of Medication Safety Expert Advisory Group MeetingThursday 9 February 2012 9.30am to 15.30pm

Board Room, Health Quality & Safety Commission, Level 6, Classic House, 15-17 Murphy Street, Thorndon, Wellington

AttendeesDwayne Crombie (Chair) Chris Cameron (CCDHB)Mary Seddon (CMDHB) David Woods (NZF)Nirasha Parsotam (HQSC) Rob Ticehurst (ADHB)Janet Mackay (PHARMAC) Sandra Fielding (BoPDHB)Beryl Wilkinson (Consumer) Avril Lee (Waitemata DHB)

In Attendance: Gillian Bohm (HQSC), Beth Loe (HQSC), Emma Forbes(HQSC)Desiree Kunac (NZPhVC) item 9, Rachel Taylor (ACC) item 10

Invited: Stewart Jessamine, Susan Kenyon, Chris James (Medsafe) item 11

Apologies: Alan Davis (NDHB), Stacey Hurrell (Waitemata DHB), Mary-Anne O’Rourke(Kowhai Health)

MinutesItem Agenda Notes/comments Action Required

Introductions The chair welcomed Chris, Desiree and Rachel to the meeting and attendees introduced themselves

1. Minutes of the 10 November meeting

Under attendees: it was agreed to amend the minutes from David Woods (bpac NZ) to David Woods (NZF) because he now worked for the NZ Formulary

The minutes were approved1a. EAG

disclosure ofinterests

Chris Cameron, Nirasha Parsotam and Beth Loe asked it to be noted that they had no conflict of interest

Alan Davis had also indicated that he had no conflict of interest

Steven Lillis had tendered his resignation It was agreed that the vacancy (for a

primary care health professional) would be advertised for a week and the appointment process used previously would be followed

Update disclosure of interest register (Beth)

Advertise and appoint new member (Beth)

1b Matters arising1b item 1 Medication Safety Governance Structure

Dwayne gave an overview of where the MSEAG fitted and its role within the governance structure

He identified the current work programme and related it to the e medicine management programme, governance and steering groups

Dwayne represented the EAG at the governance group meetings but following Mary’s resignation from the steering group there is no one from the EAG attending those meetings

Liaise with secretariat of steering group regarding a joint meeting (Beth)

Invite Peter Gow to attend joint meeting (Beth)

Prepare background paper for EAG members prior to joint meeting (Beth)

Agenda one item

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Nirasha/Beth will go to NICLG in the future and Nirasha is invited to the next meeting

NICLG also need to interact with the steering group

Proposed that a joint meeting with the steering group be held and invite chair of NICLG to attend

NICLG also need to interact with the steering group

Try to align the dates for next meeting with the steering group meeting and arrange a shared lunch followed by a joint meeting

The e collaboration group was identified as another interested party who have new terms of reference that include a safety brief

The group contributed ideas for future work streams and possible priorities and it was agreed that these would be discussed one at a time in future meetings

The requirement to include numbers needed to treat and the relative risk when discussing treatment with consumers was discussed but it was agreed that there was a need to educate health professional on how to do this and where the information could be found

It was agreed that Dwayne would write to Commission CE in the next 7 days regarding the group’s concerns on both the e medicines management cost benefit analysis and business case

from future work streams list with a paper for future EAG meetings (Beth)

Communicate concerns to Dwayne about e medicine management business case and CBA (All)

1c item 19Clozapine

The clozapine guidelines for cardiac monitoring were discussed further after Prof Peter Ellis had commented that there was currently no group in NZ who worked across the boundaries and could coordinate ensuring the guidelines were approved by funders, psychiatrists and cardiologists

Discussion around whether it was appropriate that the group took on this role because it might extend to other guidelines

It was agreed that Waitemata DHB who had produced the guidelines should be contacted in the first instance to see if the guidelines were in use and followed for every patient or if they had been updated

It was agreed to contact Prof Ellis to ascertain whether international guidelines existed

Contact Waitemata DHB regarding their guidelines (Avril)

Contact Prof Ellis regarding international guidelines (Chris)

1d item 20 Methoxyflurane

Beth reported that the question regarding the ambulance protocol and any reports of adverse effects had been passed on from her initial contact and she was awaiting a reply

Update as necessary (Beth)

1e Standards for primary care practice management

Nirasha reported that no standards currently existed but that this raised questions about who was working in this area and lack of clarity that the MSEAG should be consulted

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There was to be a presentation at the next NICLG meeting from a company who had submitted a proposal to develop ‘My list of Medicines’ but this name was actually in use by another company

HISO and Patients First working together on standards for messaging in primary care

2. a Medicationsafety programmeupdate

The HQSC Board medication safety programme update was provided for information

b. NationalMedication Chart

The long stay pilot is coming to an end and the initial feedback at the 2 week focus groups was predominantly positive

The end of pilot focus groups are taking place in the next two weeks

There was a discussion about the long stay wards that are piloting having to revert to the 7 day chart and it was agreed that this was not good practice if running a PDSA cycle

It was agreed that the DHBs concerned would review their stock holdings and also the number of charts they would need to continue using the 16 day chart until May 2012

The cost of a small print run for the 16 day chart would be determined

The consultation on the paediatric chart requirements had commenced

The project scoping documents for the development of an aged residential care chart were to be reviewed and a provider selected next week

Provide numbers of charts needed at CMDHB (Mary)

Contact MCDHB regarding their numbers (Beth)

c. Medicine reconciliation (MR)

All 20 DHBs are providing some level of MR service at admission. Dunedin Hospital is the only major hospital that doesn’t currently provide a MR service

Work with CMDHB on their prioritisation tool to identify high risk patients is on going

It was agreed that the tool needs to be validated before it or elements of it can be adopted by other DHBs

The working group who are considering prioritisation at a national level comprises Rob Ticehurst, Billy Allan, Julie Vickers, Eunice Cu &Tracey Watson

The MR standards are being reviewed in conjunction with HISO

d. eMedicinesprogramme -electronic prescribing and administration (ePA) and electronic MR (eMR) cost benefit analysis and business case

These updated versions have been accepted with reservations by the Commission Board

Feedback on both of these was discussed under item 1b

A significant concern expressed by all members was the proposed time frame for both the pilot evaluation and the roll out nationally following completion of the pilots

The Commission is still looking to appoint a dedicated clinical resource to manage

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the e medicines implementation and was looking for a doctor to be the clinical lead

The group felt strongly that a clinical lead and dedicated project management was needed

3. Prioritisation of EAG work

The prioritisation framework developed for the Commission Board was discussed

It was agreed that this would form the basis for deciding priorities for future work but further work on a scoring system may be needed

The use of case studies was discussed 4. Measuring and

evaluation The outcome of the request for proposals

for partners to work with the Commission on measuring and evaluation was discussed

The Universities of Otago and Auckland and Joanna Westbrook at the University of NSW would be working with Sapere, who would provide the lead, in developing a proposal going forward

The proposal would be relatively practical rather than epidemiological to prevent an excess burden being put on the DHBs

The difference between system level improvements and high level projects were discussed

It was identified that there was no money allocated for specific projects although the e medicines programme may have money allocated

David, Rob and Desiree had all received questions from Sapere to comment on

A proposal from Sapere would be presented to the Commission and Chris, Mary and Sandra volunteered to help review the proposal either at a workshop or via webinar

Link Chris, Sandra and Mary into measuring and evaluation proposal work (Nirasha)

5. New Zealand Medicine Formulary

A proposed prescribing, administration and dispensing section for the NZF was discussed. The content was based on medication charting standards, SQM abbreviations alert, ISMP and ISMP Canada recommendations

It would be presented as a tab on the screen because the NZF will only be published as an electronic resource

It was discussed whether anyone would read it but the advantage of having it available as a reference for education purposes was highlighted

Suggested dividing the section into tips for prescribing, dispensing and administration

Suggested making it more balanced and include more primary care prescribing messages e.g. review favourites lists at regular intervals

Could numbers needed to treat and relative risk advice be included?

It was suggested that high risk medicines should be hyperlinked at the point of

Review content and circulate for comment by email (Nirasha)

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prescribing The help of a professional writer was

discussed but anything written would be reviewed by the NZF Editorial Board

6. Medication safety and information technology – where to next

Future scan of what the next IT related projects should be and the medication safety component

Regional IT forums are established and regular updates on what they are doing in regard to medication safety would be good

Regional chronic disease pilots are also active and how do these link with IT innovations

Bar coding to point of care should still be on the agenda, CMDHB are trialling matching the patient bar code to the barcode on medicines packed in boxes where a bar code is available

Some work looking at standardising the wristband bar codes to link to the patient’s NHI would be useful

Consideration should be given to what is happening in Australia and US

Add IT innovations to future planning list (Beth)

Add regional IT updates to agenda (Beth)

7. Health Literacy and Consumer Engagement

The patient pamphlet content was discussed

There were comments that it was too wordy with too much information and that it should go to a professional writer

It had been through a health literacy expert and various consumer organisations for review previously

The current format was only used for ease of review, the leaflet had now been sent to a graphic designer to be put into the same format as the medicine reconciliation pamphlets

There would be pictures and graphics David had some work on health literacy

that he would share at the next meeting Health literacy would also be discussed as

one of the future priorities programme

Agenda leaflet after converted to production format (Beth)

Health literacy papers (David)

8. ‘Medication Safety Watch’ newsletter

The proposed format for the newsletter to replace the SQM newsletter was discussed and various changes suggested

These would have to go through the communications people at the Commission who had designed the proposed version

It was agreed that 5 editions a year would be appropriate

Focus would be on adverse drug events and incidents in New Zealand

Update format with HQSC communications team (Nirasha)

Update first edition of newsletter with suggested changes (Nirasha)

9. NZPhVC update Desiree presented the NZPhVC report on the Medicine Error Reporting Project (MERP) in primary care. An aggregated summary for the first 4 months of the pilot was presented

38 general practices and 28 community pharmacies have been recruited for the pilot

Between 1.10.2011 to 31.1.2012 242 reports had been received & reviewed

Add Desiree to EAG distribution list (Beth)

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It is interesting to note that 27 of the 54 reports related to incorrect medicine category were associated with LASA medicines

The 4 paracetamol related error reports were wrong dose or wrong strength errors

The project is funded until May 2012 and funding going forward is being explored e.g. HQSC

Comments from hospital MSEAG members indicated that often the name of the medicine can’t be used to search the hospital incident database

The MSEAG was very supportive of the pilot because of increasing consistency in reporting especially from primary care and the medication safety learning that would result

Desiree presented her discussion paper on the relationship between the NZPhVC and the MSEAG and the following were agreed:o A representative from the NZPhVC will

attend alternate meetings of the MSEAG but will be included on the group circulation list for information. This may need to be reviewed going forward

o At meetings where the NZPhVC representative is in attendance they will provide a report focusing on the MERP activities but including any other items of relevance

o Error reports that result in severe patient hard or events with a high potential for harm will be notified to the chair of the MSEAG so that appropriate action can be taken

o The NZPhVC may informally seek opinion or discuss potential issues with MSEAG members

o NZPhVC will work with the MSEAG to help develop medication safety solutions

10. ACC report Rachel presented the latest ACC treatment injury report and described some of the major case reports including some involving dabigatran

Some cases involved bridging of anticoagulation treatment e.g. patient on warfarin transferred to enoxaparin for surgery, re-started on warfarin but enoxaparin discontinued without waiting until INR was in therapeutic range

ACCs next case study will be on paracetamol

It was clarified that Medic alert bracelets are not funded through ACC even if a patient has had an anaphylactic reaction because of an allergy

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Technical Agenda

11. Dabigatran Medsafe presented the latest information on dabigatran that had been presented MARC recently

The need for a joint approach between Medsafe, PHARMAC and the MSEAG was discussed

The risk management plan for dabigatran was outlined

There was a discussion about the difference in numbers between warfarin treated patients and dabigatran treated patients and number of ADRs and that these were presented without an explanation that it was a valid comparison because ADRs to warfarin are no longer reported

It was mentioned that there had been a lack of information provided to both health professionals and patients prior to dabigatran being funded

The need to provide consumer information in a suitable format and language was emphasised but the obstacles to this in terms of the need for a legislative change were explained

Need to develop a set of criteria for assessing medicines that will be considered as part of registration and funding that will identify if Medsafe and PHARMAC should alert the MSEAG prior to the medicine being made available so that all appropriate steps can be taken to put in place a system to reduce the risk to the consumer

What has happened with dabigatran has dented the consumer’s confidence in both the prescriber and the regulator

Develop set of medication safety criteria for assessing medicines prior to registration/funding to identify medicines requiring special consideration (Beth)

12. Intensive Medicines monitoring Programme (IMMP)

Medsafe outlined their policy in regard to post marketing surveillance for medicines

There was a discussion on the role of IMMP

13. Labelling and packaginga. Tall Man

lettering The paper on Tall Man lettering was

discussed and it was agreed that there was very little evidence that showed using it prevented errors however it was agreed that in electronic systems no other system had been identified that might prevent wrong selection errors from drop down menus

There was a need to ensure that if a NZ list for Tall Man lettering was developed it would be adopted by system providers

Rob spoke on behalf of the NZULM and stated that the NZULM would adopt the a NZ Tall Man lettering list

Contact the Australian Commission regarding using their work (Nirasha)

Develop project plan for development of NZ specific list (Nirasha, Rob, David)

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It was agreed that the Australian Commission should be contacted regarding their Tall Man lettering list and if allowed that would form the basis for a NZ list

It was agreed that Nirasha, Rob and David would provide support for this work as a subcommittee of the MSEAG

b.Recommended wording to express concentration for labelling standards

Rob gave an update on what was happening regarding standardising the wording used to express concentration on labels

Medsafe had agreed that the NZULM terminology for expressing concentration would be mandated for all new medicines and any products applying for new labelling

It was agreed that Medsafe should be thanked for mandating this requirement

Write to Medsafe thanking them for mandating NZULM terminology for expressing concentration (Beth)

14. Look alike sound alike issuesa.Paracetamol & paracetamol with codeine tablets

From February the funded paracetamol and paracetamol with codeine tablets are essentially indistinguishable (the diameter differs by 1mm) when removed from the packaging

When packaged into blister packs this creates a risk of dispensing errors in community pharmacy

A warning had been included in the proposed Medication Safety Watch and in the Pharmaceutical Society, Pharmacy Guild and Pharmacy Council newsletters

15. Prioritisation of high risk medicine work

The group agreed that an oxycodone alert should be developed based on previous alerts developed by DHBs and including the re-issue of the updated identification chart originally developed by CMDHB

The development of an insulin toolkit was discussed at length because of the variety of possible errors that could arise with insulin

It was agreed that a project brief scoping the scale of work required to reduce insulin errors in both primary and secondary care be prepared

The brief should include the development of an e learning module based on the Waitemata DHB module

Develop oxycodone alert (Beth)

Develop project brief for reducing insulin incidents (HQSC medication safety team)

16. Proposed format for EAG alerts

The HQSC design for the medication alerts was discussed

Some design changes were agreed and these would be raised with the HQSC communications team

Update design with agreed changes (Beth)

17. Oralmethotrexate

There was discussion around the wording of point 2 organisational level

It was agreed that the wording shouldn’t emphasise the ‘number of tablets’ because of the errors associated with patients taking the same number of tablets being taken when the strength is changed

A requirement to audit prescriptions is in

Update alert and action plan for issue in March (Beth)

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the action plan at the suggestion of the GP member of SQM but the details had not been worked out and the group would be unable to easily monitor this was occurring

It was agreed that the need for audit should be left off the action plan but would be considered in future action plans

18. Other alerts in development: Paediatricweight baseddosing, Renal Drug Dosing, Transdermalpatch

These would be discussed and agreed at future meetings

Agenda at future meetings (Beth)

19. Paracetamol induced liver transplants in childrena. bpac journal

Minor wording changes agreed Submit to bpac for publication (Beth)

b. Kaitiaki article

It was agreed that the content should be medication safety focussed and the pharmacology information should be removed

The need for the addition of key messages was agreed

It was agreed that the same sort of information should be developed for inclusion in Pharmacy Today so that the message would also reach community pharmacists

Agreed there would be value in developing a short rapid alert

Discussed the use of media to spread the word e.g. health journalists and GP TV. The cost of TV’s Health Diary was prohibitive

New wording for article (Sandra)

Circulate new wording for final agreement (Beth)

Develop article for Pharmacy Today (Beth)

Develop short alert (?)

20. NHI allergy alert issues

Information from CARM is that it does not take 6 weeks for the new alerts to be linked to the NHI

It was raised that one DHB who link DHB added alerts to the NHI give a phone number to contact for further information rather than the details of the alert

Chris suggested that the allergy alerts could now be viewed by GPs

Check regarding alert visibility in primary care (Chris, Beth)

21. Health Select Committee from MSEAG on natural products

The draft feedback was agreed Submit feedback to Health Select Committee (Beth)

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