Kyle Malone, Pharmacist, MPharms MPSI, looks at how medication safety in Australia can be improved by implementing a learning health system.

Although medicines are the most common form of treatment in healthcare systems, their use can be associated with troublesome side-effects, adverse drug reactions, as well as the risk of more serious harm.

In particular, unsafe medication practices and medication errors remain a leading cause of patient injury. A recent publication from the Pharmaceutical Society of Australia (the PSA) entitled “Medicine Safety: Take Care” highlights the extent of the problem in Australia alone (1).

Here, we look at the key messages of this report. Furthermore, we discuss a possible remedy for issues of medication safety in the form of the Learning Health System approach.

In Australia, approximately 250,000 hospital admissions per annum come as a result of medication-related incidents.

In emergency departments, an additional 400,000 cases are likely attributable to the same cause. At this scale, it is estimated the problem costs the country a staggering $1.4 billion a year.

Tragically, 50% of the harm is considered preventable.

In the eyes of Australian clinicians, being preventable would mean the problem was “recognisable, the adverse outcomes foreseeable, and the causes and outcomes identifiable and controllable” (2). This also shows the opportunity for improvement if the right focus is applied.

On October 9th, 2017, Australia joined the WHO-led international push to halve medication errors by 2020. As highlighted below, the country is still grappling with high levels of medication-related incidents, in which medication errors play a crucial part.

And yet, it is the very report that highlights the severity of the issue that also offers hope.

Adverse Drug Reactions (ADRs)

Unpacking the data around medication-related hospital admissions allows a number of clear themes to emerge. The first concerns adverse drug reactions (ADRs).

In one study cited in the report, roughly 1 in 5 hospital admissions listed an ADR as a cause or contributing factor. In many instances, patients were suffering from multiple reactions at the same time.

Statistically, one-third of the sample showed two ADRs, while 15% of patients presented with three or more.

However, in the vast majority of cases (87%), even a single ADR need not have occurred. Despite knowledge of the problem, as well as the contributory factors behind it (7 in 10 ADRs, for example, were tied to multiple medicines use), recurrence rates remained high.

In fact, 13% of patients admitted with an ADR found themselves in a hospital bed with the same complication again within 12 months.

Inappropriate Prescribing

A second issue identified in the report is the relative abundance of inappropriate prescribing. In a study of patients 65 years and older, for example, 55% of the sample took a potentially inappropriate medicine, with 6% of all medical and surgical admissions due to the same medication.

In a separate study, 40% of people were on potentially inappropriate medicines at the time of admission, whereas the prescriptions of roughly 6 in 10 showed potential prescribing omissions.

The authors estimated that one-third of the medication usage could be associated with a potentially adverse clinical outcome.

Transition of Care

Nowhere, however, are the shortcomings in medication safety as visible as at the transition points of patient care.

Studies suggest over 90% of patients experience a change in medication during a hospital stay (3, 4). Even so, discharge summaries are frequently illegible, incomplete, or contain no medication lists at all. Details including medication dose, frequency, and route of administration are likewise often omitted.

As a result, and perhaps unsurprisingly, over 90% of patients have at least one medication-related problem post-discharge. As with hospital admissions above, such problems often centre around the prescribing of potentially inappropriate medications.

While the statistics in the Australian acute care settings are alarming, a similarly bleak picture can be painted in the community and in residential aged care. One in five patients in the community, for example, are likely to be suffering an ADR at the time they receive a Home Medicines Review (with an average of four medication-related problems noted per patient).

Overall, at any one time, 1.2 million Australians will have experienced an adverse medication event in the previous six months. Behind this figure, again, lies the issue of potentially inappropriate prescribing, which in the community shows an annual prevalence of 40%.

In residential aged care, on the other hand, rates of potentially inappropriate prescribing stretch to 80%. In total, more than 9 in 10 residents in aged-care facilities have at least one medication-related problem.

What is the Solution?

Given the enormous role medication safety plays in this setting, it comes as no surprise that interventions which aim to simplify medicine administration are often used. Nevertheless, despite the effect products such as dose administration aids have on medication errors, more rigorous and systematic approaches are required in order to truly improve patient care (5).

Research suggests pharmacists can play a leading part in such programs. A study in Melbourne, for instance, highlighted that 3 in 5 hospital discharge summaries prepared in the absence of the pharmacists have at least one medication error.

The introduction of the “My Health Record” in Australia will also further boost the ability of pharmacists to proactively intervene in medication safety-related events. My Health Record, similar in many ways to an ePrescribing platform, represents a common health infrastructure.

In this case, the infrastructure acts as a data store for clinical biomarkers and test results.

[su_box title=”Medication Error Minimisation Scheme” style=”bubbles” box_color=”#64912e”]In a 2013 paper describing the first three years (2009-2012) of the Medication Error Minimisation Scheme, an increased rate of medication incident reporting was noted (6.2 vs. 14.9 reports per 1000 patient days), while the overall number of errors also decreased. [/su_box]

A separate PDCA (Plan, Do, Check, Act) cycle-based project examined the development of a model to reduce medication errors and harm in children. Results showed a reduction in total errors at years 1 and 4 of the project, including a fall in actual and potential adverse events (6).

Plan Do Check Act PDCA

Separate infrastructures exist with the aim of reducing medication-related events. Such platforms, founded on the concept of continuous quality improvement (CQI), lean heavily on the learning health system (LHS) philosophy.

In Australia, rudimentary versions of these platforms have been tested using simplified Plan-Do-Check-Act (PDCA) cycles.

Pharmapod provides a platform which goes one step further, building on the foundations of PDCA.

Through the iterative collection of medication error-related data, the Pharmapod platform both contributes to the global aggregate medication incident database and also enables healthcare professionals to efficiently record continuous quality improvement efforts for compliance purposes.

Improvements in patient safety and the reductions in medication error rates can be easily demonstrated. More importantly, healthcare professionals can share experiences, facilitating a conversation on patient safety which transcends international borders.

In this way, Pharmapod not only delivers on the goals of local business but also realises the vision of the long-awaited global learning health system.

Kyle Malone, Pharmacist, MPharms MPSI,
PhD Researcher,
School of Pharmacy,
University College Cork

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    1. Pharmaceutical Society of Australia 2019. Medicine Safety: Take Care. Canberra: PSA.
    2. Caughey GE, Kalisch Ellett LM, Wong TY Development of evidence-based Australian medication-related indicators of potentially preventable hospitalisations: a modified RAND appropriateness method BMJ Open 2014;4:e004625. doi: 10.1136/bmjopen-2013-004625
    3. Mant A, Rotem WC, Kehoe L, Kaye KI. Compliance with guidelines for continuity of care in therapeutics from hospital to community. Medical Journal of Australia. Mar 19 2001;174(6):277–280.
    4. Stowasser DA, Collins DM, Stowasser M. A randomised controlled trial of medication liaison services – Patient outcomes. Journal of Pharmacy Practice & Research. 2002;32(2):133–140
    5. Australian Commission on Safety and Quality in Health Care (2013), Literature Review: Medication Safety in Australia. ACSQHC, Sydney.



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