1. 32
PROFESSIONAL
P R A C T I C E U P D A T E S
THE AUSTRALIAN JOURNAL OF PHARMACY VOL.93 AUGUST 2012
32
I
n February 2011 Outback
Pharmacies asked me to
undertake a review of their three
pharmacy operations based in and
around Broken Hill in NSW. At that
time it provided pharmacy services
to approximately 160,000 square
kilometres, had served the Royal
Flying Doctors Service for more
than 50 years, had a well-established
relationship with the local Aboriginal
Health Service, provided services
to the local nursing home and had
begun exploring options on working
more collaboratively with the
local health district and University
Department of Rural Health.
Although the review is ongoing,
there has been significant advances
and improvement in pharmacy
services in the region so far. A major
area identified for improvement
was the process of transitioning
of patients in and out of the local
hospital. But what does this issue
have to do with Outback Pharmacies?
The review identified that there were
significant economic, sustainable
and clinical issues with the status
quo, particularly given that Outback
Pharmacies provided services to the
local nursing home and Webster
packing services to approximately
80% of the local community who
receive a Webster pack.
The major issue identified by the
review was that medications being
taken by the patient prior to being
admitted to the local hospital: may
not have been continued; may
have been changed with no clinical
reasoning; and/or had additions
which did not appear to have a
clinical indication. Often when a
patient was discharged from the
local hospital Outback Pharmacies’
pharmacists and technicians would
be asked to see what medications
the hospital pharmacy department
needed to be supplied. During
this process staff often queried
why ‘X’ medication ceased, why ‘Y’
medication was reduced in dose and
so on. Yet there was no confirmed
means of communication between
us, the medical staff at the hospital
and then back to us.
Communication is not successful
unless there is a feedback
mechanism—information needs
to be understood by the receiver
before the sender’s communication
objectives can be deemed to have
been achieved. Hence, Outback
Pharmacies needed confirmation
that the treating medical team had
been provided all the information
about the patient’s medications to
ensure that they could make a fully
informed decision. The veracity
of such an approach is confirmed
by The Medicines Management
Pathway, developed by Stowasser
DA, Allinson YM, O’Leary KM.
Queenslandhealthhasundertaken
significantresearchinrelationto
medicationreconciliation.That
researchsuggestedthatupto50%of
patientsadmittedtoahospitalhad
incompletemedicinelistsprovided,
resultinginmedicinesnotbeing
administeredduringtheirhospitalstay.
Ofthese33%hadamoderateclinical
deteriorationand6%hadasevere
clinicaldeterioration.1
Athospital
discharge,listssenttocommunity
healthcareprofessionalswere
associatedwitha2.3-foldincreasein
riskofhospitalreadmissionoradverse
medicineevent.2
Thereviewraisedconcernsthat
chartsprovidedtotheEmergency
Departmentfromthenursinghome
maynothavebeencomplete.Had
busycircumstancesresultedin
perhapsonlythreeoffourchartsbeing
provided,ormaybeanoldchartor
evenanotherpatient’scharthadbeen
provided;wejustdidnotknow.Nor
didweknowwhetherthefaxmachines
skewedorblurredtheinformation,
suchasmakinginstructionslike‘onea
day’appear‘twoaday’tothereceiver.
Wejustdidnotknow.
So,inmid-2011Iarrangedameeting
withthechiefexecutiveofficerof
theLocalHealthDistrictStuartRiley
wherewediscussedtheseconcerns.
Iproposedtoinvestigateopeningup
ourdatabasetothehospitaltoenable
accesstotheinformationonthese
patientsallthetime.
Interestingly, I was asked why
anyone would need to know the
information from the pharmacy
when ‘we already have access to
the prescribing information from
the general practices’. The key to
this answer is that research points
to around 30% of prescriptions
written not being filled.3
Regardless
of whether the 30% figure is accurate
this research reinforces that the
information held by the general
practice may not be accurate,
complete and/or timely.
A patient may have been admitted
to the hospital and the discharge
letter may not have reached the
general practice. The patient
may have also seen a specialist
at another facility and had their
LEFT: Stuart Riley, CEO, Far West Area Health District, Andrew Olesnicky, director of Emergency, Medicine Broken Hill Base
Hospital, and Dan O’Halloran, manager Finance/Governance/Strategy. RIGHT: Sharon Williams, director of Care Service, Southern
Cross Care Broken Hill and Julie Wilkinson RN, Harold Williams Home.
By Dan O’Halloran B.Comm B.Pharm CPA GAICD MPS
PATIENT SAFETY FOLLOWING HOSPITAL
ADMISSION AND DISCHARGE HAS BEEN
IMPROVED IN BROKEN HILL DUE TO
INNOVATIONS AND COLLABORATION LED
BY A PHARMACIST.
Outback innovation
improves safety
PHOTOSBYDARRINMANUEL

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medications changed. Is this always
communicated to the general
practice? We hope so, but we don’t
know that the general practice will
have received a discharge letter in
a timely manner to actually use it?
For example, normally the public
hospital will provide five days of
medications on discharge. But if
it takes two weeks for a discharge
letter to reach the general practice,
what happens between Day 5 and
Day 14 when the patient requires
the medication?
In light of all of this we concluded
pharmacy held the most accurate,
up-to-date and complete
information about a patient’s
medications; particularly if the
patient is having their medications
packed by the pharmacy.
I began to investigate what
products there were on the market
and soon concluded that it would
be a legal nightmare trying to share
the pharmacy’s entire dispensing
history—the Privacy Act becomes
relevant if a patient’s medication is
accessed by a third party when there
was no clinical need. Deciding to take
the challenge one cautious step at a
time, I focused on the key problem:
the discharge of patients who were
residents of the local nursing home.
I finally came across MedsComm, a
product owned by Webstercare and
designed to communicate between
the nursing home, GP and pharmacy.
I contacted Webstercare and told
them my issue and asked permission
to change ‘the doctor’ to ‘the local
emergency department at the
hospital’. The rest is really history.
Now the Broken Hill Base
Hospital Pharmacy Department and
Emergency Department can access
information 24 hours a day (updated
every 15 minutes) on patients that
we pack websterpacks for. Yes,
there were more privacy matters
that needed further consideration
and sorted through these. We asked
every patient whose data we wanted
to share to sign a release document
stating that they approved sharing
their data with their doctor and
the local hospital. I also wrote a
Memorandum of Understanding
with the CEO of the Far West Local
Health District on a cost-share
arrangement—the cost of the system
would be paid 50% by the FWLHD
and 50% by the Outback Pharmacies
group of community pharmacies. If
all the pharmacies in town signed up
tothisMOUBrokenHillwouldbethe
first community that I am aware of to
have 100% of those in the community
who receive a websterpack to have
their information available 24 hours a
day by the local hospital.
A key question is who has access
to the system. Because of a reliance
on locums in the Base Hospital it was
not sustainable to have them trained
and responsible for accessing this
information. So we have decided
to train the clerical staff. When a
patient is admitted the clerical staff
check the system and print off the
current medication list so that it is
available for the doctor to review the
patient. This same list is printed on
discharge including any changes,
such as new medication added, and
sent back to the pharmacy. This
allows the pharmacy to know that the
doctor was fully informed of all the
medications the patient was on prior
to their admission.
The primary aim of the system was
to improve patient health and safety
outcomes by reducing medication
errors and hospital rebound rates
while also improving workforce
efficiencies. Although such an
outcome is yet to be independently
confirmed and nor is the system
yet being fully utilised, anecdotal
evidence suggests the system has
made a significant improvement
to patient safety, medication
management and workforce
efficiencies.
References available on request.