The first part of the Framework focuses on an intervention framework of reducing adverse events.
I. PreventionFor effective education about the consumer's medication and conditions, it is important to encourage prescribers to provide, and consumers and carers to ask for, written information in addition to oral advice, and preferably the combination of both. Consumers and carers need to be educated about how to use medication and other treatments effectively – in particular how to take medications correctly, what effects to expect, when to expect the results, how to monitor the effects, what to do if the treatment does not work as expected and what to do if an adverse drug reaction is experienced. The risk of adverse medication events also occurring in the long term with the use of certain medications – in many cases over a number of years – needs to be recognised and this information communicated by prescribers and dispensers to consumers and carers.
All prescribed medications are required to incorporate Consumer Medicine Information (CMI) but some reviews of the effectiveness of the CMI have been critical. It is therefore important that the CMI is accompanied by careful explanation and advice by prescribers as to the specifics of the particular medication. This supplementary advice could be enhanced by a separate document that accompanies the CMI that could be provided at both the prescribing point and the dispensing point. It is therefore important for prescribers and pharmacists to work together to communicate and educate consumers, and where appropriate carers, about the medication. This additional document would ideally include appropriate and useful information such as general information about the condition for which the particular medication is prescribed. Additional information in relation to general groups of psychotropic medications, the possibility of adverse medication events occurring with the use of these medications in the long term, associated side effects and concerns regarding safety issues should also be provided as appropriate. Together with the CMI, this document should be available through a variety of pathways including on a national website, which is linked to other relevant sites. Top of page
Improvements in medication management systems and associated tools, such as the Medication Safety Assessment Tool, when properly implemented have assisted improvement in reducing adverse medication events. However, these tools are not consistently available in all settings. A range of resources need to be available to Community Mental Health Centres, private psychiatrists and general practitioners to provide information for consumers and carers to further enhance the safety and effectiveness of medication use, specifically associated with the treatment of people with mental health problems.
In addition, adverse event reporting needs to be enhanced in a significant way for consumers, carers and providers. A variety of "channels" to achieve this should be made available, including through print and electronic media and through peer group channels.
- Provide oral and written advice regarding medications
- Educate on correct use of medications
- Advise of possible side effects and how to monitor possible effects
- Advise course of action in case of an adverse drug reaction. Top of page
II. Risk reductionConsumers and carers require education in relation to medication use and should be encouraged to directly discuss all issues of medication use with the prescriber. This discussion should take into account the consumer's own responsibility for his/her health and long-term management, particularly the importance of medication compliance. Hospitals also have a responsibility to inform consumers and carers about the importance of continuing medications and other treatments, particularly when transitioning in and out of inpatient care. Specialists also have a responsibility to discuss medication maintenance issues with consumers, both prior to and post hospitalisation.
In particular, mental health services in both the public and private sectors may need to consider resourcing requirements to provide follow up within 14 days of discharge to:
- check the consumer's progress
- check for side effects and any indications of toxicity
- provide counselling to consumer and carer
- check consumer's, and where appropriate the carer's, understanding of the condition and what needs to be done to aid recovery
- check the consumer has a recovery plan
- check the consumer, and where appropriate the carer, knows what to do to reduce risks of further events and prevent further harm
- check the consumer has all the medications prescribed. Consider accessing a 'home medication review' by a specially qualified pharmacist following a request from a GP
- check medication use and
- check the consumer's links with doctors, pharmacists, nurses, rehabilitation, physiotherapists and specialists. Top of page
Adverse events reporting by consumers, carers and health professionals needs to be encouraged and enhanced and this information integrated into national or jurisdictional databases which can be used for trend analysis and reporting. It is important to resource consumer and carer tools and training on the monitoring of medication, including its positive and negative effects.
- Stress importance of medication compliance
- Ensure medication supply and continuity at transitioning points including discharge
- Follow up within 14 days of discharge Top of page
III. System learningProfessional bodies and Government need to find demonstrable ways to improve communication between prescribers and pharmacists and promote these methods to the professions. Pharmacists are in a unique position to often know about the totality of the prescribed medications and complementary medicines that a consumer is taking and there needs to be more effective communication channels developed between them and prescribers about the combination of medications that a consumer is taking at any one point.
Medical practitioners, nurse practitioners and other practitioners, who may be authorised to prescribe in the future, should be informed of prescribing and dispensing options that help consumers manage their medications, including the cost of treatment.
It is also important to increase community understanding of mental illnesses and treatments to enable a balanced discussion of benefits and harms of medication use.
System learning, from data analysis of adverse medication events reporting, is an important part of the application of the QUM framework. System learning will follow from the improvements in reporting at the jurisdictional and national levels. Improved reporting, in turn, will help focus application of specific remediation at the particular points where problems are identified and will thereby contribute to reduce adverse medication events.
Improvement in QUM relies on changing the behaviour of the participants and involving key people in the process. This approach has been successful in areas such as diabetes and asthma where consumers, professional bodies, federal and state governments and the community have been part of a successful education process. Attempts to engage with mental health have been less successful and mental health is now recognised as a prime focus for development. It is important to develop and resource more effective educational methods to encourage positive change in health professionals' prescribing behaviour. Top of page
There is international evidence demonstrating that data sets are critical in improving QUM. In Australia we have a number of data sets that could be used to improve the quality of medication management at the clinical team, hospital, jurisdictional and national levels. It is important to make use of existing information, particularly as data collection is enhanced, to inform continuous improvement of data sets. In addition, to be most effective, these data sets need to be brought together and aggregated and coordinated more effectively. The National Prescribing Service (NPS) has a major and central role in this process. It is also important to continue to build a better understanding of what QUM is amongst consumers and carers.
Evaluation and outcome measurement for different types of interventions as part of QUM is an important aspect in understanding the effectiveness of such interventions and continuous improvement. A number of interventions have already been assessed in an attempt to understand the nature of risks, gaps and remediation in QUM. This includes Disguised Observer Studies, Unit Dose Drug Distribution System Studies and Chart Analysis Studies. Other approaches have included stratifications to assist specific interventions including a focus on identification of high risk medication groups and particular drugs and high risk situations.
There has been only a relatively recent focus on these types of approaches and it is expected that there will be further developments to assist in the identification and understanding of safety and risk in QUM. Additional findings will need to be progressively incorporated in the framework as they apply to this area.
- Improve communication between prescriber and dispensing agent
- Ensure system learnings are incorporated into local level protocols
- Systematic improvement of data collection and incorporation into continuous improvement of addressing adverse medication events. Top of page