On Thursday 26 November, VAHI hosted a virtual report release event which showcased the recently released Medication incidents - an analysis of Victorian Health Incident Management System (VHIMS) data report.
The report launch was well attended by 126 people across Victorian public and community health services.
After a brief introduction by Dr Lance Emerson, CEO of VAHI, the event commenced with a presentation on the report’s findings by Ms Megan Goadby, VAHI’s Manager of Safety and Surveillance. This presentation outlined:
- the analysis was based on VHIMS data submitted by 128 Victorian public and community health services for the period 1 July 2017 to 31 December 2019
- of all clinical incidents reported, approximately 16% or 83,191 were medication incidents; and
- 64% of all medication incidents occurred during the administration of medication.
Following this presentation was an interesting panel discussion commencing with Ms Sophy Athan, a consumer representative who provided a system-safety perspective from the viewpoint of a patient or user of the health system. Ms Athan emphasized the importance of communication between patients and clinicians to ensure appropriate medication is prescribed in line with the patient’s wider health background.
Professor Michael Dooley (Director of Pharmacy at Alfred Health, Professor of Clinical Pharmacy, Centre for Medicine Use and Safety at Monash University, and Adjunct Professor in the Department of Epidemiology and Preventative Medicine at Monash University) then spoke about some of the challenges and opportunities faced in reporting medication related incidents at Victorian public health services. Professor Dooley noted the complexity of prescribing medication and referred specifically to the ‘Partnered Pharmacist Medication Charting Model’ (PPMC) study, which involved collaboration between clinicians and pharmacists in developing medication management plans for hospital patients. The study found a significant reduction in the proportion of medication errors and a reduction in patient length of stay when the PPMC was used.
Professor Harvey Newnham (General Physician and Endocrinologist and Professor and Director of General Medicine for Alfred Health) then discussed what the evidence suggests for improvement in the quality and safe use of medicines. Professor Newnham regarded a culture of situational awareness where everyone feels comfortable raising their concerns when something isn’t right as one key way to improve medication safety.
Ms Amy Noble (senior palliative care clinical nurse consultant for Peter MacCallum Cancer Centre and the Royal Melbourne Hospital) further agreed, and commented that while nursing staff play a big role in medication administration, it is not their only task. Ms Noble spoke about some of the challenging circumstances that arise in the administration of medication given the many other distractions.
Dr Kylie McIntosh (Medicines, Safer Care Victoria) outlined some of the initiatives underway by Safer Care Victoria in partnership with health care providers to support improvements in the area. These initiatives include the expansion of the PPMC program and the Australian Commission on Safety and Quality in Healthcare’s online learning modules for clinicians about high risk medicines.
A lively question and answer session followed the panel discussion, discussing topics including the financial burden of medication-related incidents on our health system, and whether the number of medication incidents has been affected by the introduction of electronic medical records in some health services.
Dr Emerson closed the session by outlining that the next VHIMS statewide report will be available in the new year and will focus on occupational violence.
The event received positive feedback from attendees, with 93% reporting that they found the information presented useful to their role. Attendees also provided a positive response to the online delivery of the event and its benefits particularly for regional and rural audiences.
VAHI would like to thank all the Victorian public health services that regularly submit VHIMS data to support statewide reporting, which assists in driving safety and quality improvements.
The event is available to watch here.
For more information about the VHIMS report, please contact Megan Goadby, Manager, Safety and Surveillance via firstname.lastname@example.org.