Medication Without Harm

Our goal is to reduce severe and avoidable medication related harm by 50% within 5 years. The quality improvement programme focusses on the following priorities:

• Improving medication safety at transitions of care
• Reducing inappropriate polypharmacyImproving safe use of high risk medications

Unsafe medication practices and medication errors are a leading cause of avoidable harm in healthcare systems across the world. Multiple interventions to address the frequency and impact of medication errors have already been developed, yet their implementation is varied.¹

An estimated medication error rate of >50% occurs when patients move between healthcare services following hospitalization² and older patients, especially those taking multiple medications, experience serious consequences.^3,4

In 2017, the World Health Organisation (WHO) launched a campaign to reduce severe and avoidable medication related harm globally by 50%.1,5 Three priorities are emphasized:making transitions of care, polypharmacy and high-risk situations safer.

In early 2020, an improvement programme was initiated in Iceland based on the framework set by the WHO.

 

References:

 

1. World Health Organization. (‎2017)‎. Medication without harm. World Health Organization.
2. Garfield S. et al., BMC Med. 2009;7:50.
3. Parekh N. et al. Br J Clin Pharmacol 2018;84:1789–1797.
4. Morin L. et al., Am J Med. 2017;130(8):927–936.e9.
5. World Health Organization. (2021).
Global patient safety action plan 2021 – 2030:
towards eliminating avoidable harm in health care. Geneva:
World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.

Access to WHO three technical reports:
Medication safety in transitions of care: technical report

Medication safety in polypharmacy: technical report

Medication safety in high risk situations: technical report   

We will achieve our aims by targeting the following needs in Iceland:

• Strengthening clinical pharmacy support across the healthcare system
• Increasing the quality of medication related processes in healthcare institutions
• Optimising medication information technology (IT) systems
• Strengthening medication safety governance
• Enhancing healthcare professional training and education on medication safety
• Engage patients and the public in medication safety

A working group was appointed by the National Steering Committee in 2020 to develop a suite of quality indicators to assess impact of the quality improvement programme

Full proposal: Falls and Bleeds in Relation to the Use of Drugs as Quality Indicators for Medication Associated Harm in Iceland.

Latest update: The proposal was submitted to the National Bioethics Committee in January 2022. Once approval has been granted, data for five years between January 2017 - December 2021 will be extracted and analysed retrospectively as a pilot to determine relevance and accuracy of the quality indicators. Learning from a pilot in Denmark will also be reviewed before prospective data collection will commence.

Our Medication Without Harm quality improvement programme focusses on the following priorities: 

1. Improving medication safety at transitions of care
2. Reducing inappropriate polypharmacy
3. Improving safe use of high risk medications

We aim to reduce medication errors at transitions of care in Iceland by:

1. Medication reconciliation 
   All patients receive timely and standardised medication reconciliation when they move from one healthcare setting to another.
2. Patient knowledge about what medications they are taking 
3. Patients and their carers receive clear and up-to-date information about what medications they should be taking.
4. Good quality transfer/discharge documentation
   Clear and timely written information and instructions about the patient‘s medication is transferred from one healthcare team to another.
5. A centralised medication record (miðlægt lyfjakort)
   Doctors have the responsibility to prescribe and update a centralised medication record. This means that healthcare professionals and patients will have access to clear, accurate and up-to-date medication information through a centralised system. 

Pilot projects have begun at Landspítali and primary care in the Reykjavík area.

Improving medication safety during transitions of care overview:

 Transitions of care workstream overview:

Medication reconciliation is defined as a process that has five steps: list the patient’s current medications; list the medications currently needed; compare the lists; make a new list based on the comparison; communicate the new list to the patient and caregivers (British Medical Journal, 2017). A discussion of the appropriate terminologies and definitions in Icelandic was published in Læknablaðið in 2021 (Lyfjasaga og lyfjarýni). The implementation of medication reconciliation has consistently shown to reduce medication discrepancies at transitions of care, reducing the risk of medication related harm. This is currently being standardized and strengthened in Iceland.

Two main interventions to improve medication reconciliation are being tested:

1. Medication reconciliation template
   
   A template to standardise the medication reconciliation process is currently being tested with a team of doctors at Landakot with promising results. It is aimed to enable healthcare professionals to consistently have good quality discussions with patients about their medications, have easy access to patients’ most up-to-date medication lists and changes, and reconcile discharge medications in a more efficient way.
   
   The template will then be tested more widely for all admitted patients through the emergency department at LSH and spread to other wards and healthcare institutions thereafter.
   
   
2. Clinical pharmacy support in medication reconciliation
   
   Clinical pharmacy support during the medication reconciliation process is also being strengthened at Landspítali. The aim is for an increasing proportion of patients who are admitted to Landspítali via the emergency department to have their medications reconciled by a trained pharmacist within 24 hours of admission.

VIDEO HERE TBC Video – clinical pharmacists 

Improving access to good quality information about what medications patients should be taking will be designed and tested after solutions for improving the medication reconciliation process at Landakot have been implemented.

This will be further enabled by the implementation of the centralised medication record (miðlægt lyfjakort) through the patients’ health portal (Heilsuvera).

Good quality written communication about medication changes when patients are transferred from one healthcare team to another is being implemented to minimise medication errors at transitions of care.

1. Transfer from intensive care units (ICU) to acute wards at Landspítali
   
   Improving the accessibility and structure of transfer notes from the ICU at Hringbraut to acute medical wards are being tested. The main challenge is transferring information safely between two teams who use different electronic health records and prescribing systems.
   
   Standards for ICU transfer notes have been set and solutions to reduce variability in their implementation are currently being tested. Improvements will then be spread to other sites.
   
   
   
2. Transfer from acute wards to geriatrics
   
   Older patients who stay for long periods of time on acute wards and need to be transferred to the geriatric rehabilitation units are at higher risk of experiencing medication errors at Landspítali. This is because they are often taking more medications (>10) and likely to have many medication changes while in hospital.
   
   A project to ensure that all patients have standardized transfer notes (læknabréf) from acute medical wards to the geriatric rehabilitation units has been initiated.
   A template and strategies to ensure doctors draft transfer documentation earlier in the transfer process (and not left to the last minute) are being tested in internal medicine wards. Solutions will be spread to other department once they have been found to result in improvement.

A centralised electronic medication record (miðlægt lyfjakort) is currently being developed by the Directorate of Health. It provides a single place for up to date medication prescriptions to be accessible to all doctors in the country.

It will be the key enabler for making medication reconciliation and medication review processes more efficient and accurate. The software is currently being tested offline in one of the Primary Care clinics in Reykjavík. The plan is for live testing to start in the first quarter to 2022 in 1-2 Primary Care clinics.

Implementation will be rolled out gradually to all healthcare institutions in Iceland over the period of approximately 18 months after that.

The aim is to improve the medication review process through strengthening support from pharmacists, use of evidence-based tools to guide prescribing practices and improve health literacy of patients in polypharmacy.

Pilot projects have started in Primary Care with an emphasis for clinical pharmacists at Landspítali to reflect their expertise beyond the hospital setting (e.g. primary care).

 

 

 

 

 

Polypharmacy workstream overview

 

 

National strategy for clinical pharmacy

A working group from Landspítali and Primary Care has been convened to develop a national strategy for clinical pharmacy support. Currently in Iceland there are too few qualified clinical pharmacists to provide consistent and widespread support to multidisciplinary clinical teams to improve medication safety in polypharmacy.

The strategy will focus on how limited clinical pharmacists’ resources should be prioritised and how their expertise can be spread to other professionals such as doctors, pharmacists, pharmacy assistants and nurses.

A pilot is currently underway in some Primary Care clinics where clinical pharmacists support GPs in medication reviews and deprescribing.

Clinical pharmacy support in primary care (Print story on Facebook)

Video – Anna Bryndís Blöndall, GP and clinical pharmacist from Landspítali.

 

under development

This workstream is led jointly by Landspítali and the Akureyri Hospital (Sak) with involvement from Primary Care and other sectors.

The safe us of high risk medications relating to A-PINCHS s prioritised: Antimicrobials, potassium and other electrolytes, insulins, narcotics (opioids) and other sedatives, chemotherapeutic agents, heparin and other anticoagulants and safe systems (e.g. 6Rs, double checking).

 

Pilot projects have started in internal medicine wards at Landspítali, SAk and in Primary Care.

 

The improvement work relating to this priority is led jointly by Landspítali and the Akureyri Hospital (Sak) with involvement from Primary Care and other sectors. The safe use of high risk medications relating to A-PINCHS is prioritised: antimicrobials (A), potassium and other electrolytes (P), insulins (I), narcotics (opioids) and other sedatives (N), chemotherapeutic agents (C), heparin and other anticoagulants (H) and safe systems (S).

High Risk Medications workstream overview

Safe use of insulins in hospital

Insulin is a high risk medication. Suboptimal or incorrect treatment for patients with diabetes in hospital leads to poor glucose control and can result in post-operative wound infections, longer stays in hospital, frequent re-admissions and preventable death.

A large proportion of medication incidents reported at Landspítali involve insulins, many of which relate to the lack of staff knowledge about how to use insulins correctly and variation in how to treat patients with insulin.

Interventions to improve insulin safety are being tested on one of the internal medicine wards at Landspítali. Solutions include: 

• Accessible guidelines on insulin prescribing, particularly for hyperglycaemia.
• Prompts to remind staff to frequently measure blood glucose.
• Staff training and education on the safe use of insulins.
• Making it easier for clinical teams to frequently check and act on blood glucose results that are out of range.

The project team is currently assessing impact of these interventions. Solutions that work will be spread to other inpatient units at Landspítali and Akureyri.

1. Understanding opioid prescribing patterns in Iceland

An analysis is being undertaken to understand opioid prescribing patterns in Iceland. The purpose of the study is to determine which patient groups are receiving multiple repeat prescriptions of opioids, what type of opioids they are receiving, and which clinical specialties are making the bulk of these prescriptions.

The findings will enable the High Risk Medications workstream to determine the root causes for why sales of opioids are highest in Iceland compared to other Nordic countries (Editorial Group for NOMESCO Health Statistics, 2020), and why research findings consistently show that 10% of opioid-naïve patients become persistent users post-operatively (Steen T, Lirk PB & Sigurdsson MI, 2019)) (Ingason AB et al.,2022).

Results of the study will be presented by Spring 2022 and an improvement plan will be initiated by the Fall.

2. Deprescribing opioids in primary care

 Deprescribing opioids in Primary Care is one of the priorities of the Development Centre for Primary Healthcare in Iceland (Þróunarmiðstöð íslenskrar heilsugæslu – ÞÍH).

Live prescribing data will be made available to all Primary Care health centres and every GP in Iceland to promote awareness of prescribing patterns (through Gagnasýn).

A deprescribing information pamphlet for opioids is also being translated into Icelandic (from www.deprescribing.org). This resource aims to facilitate better patient and caregiver communication with doctors about the deprescribing process. They are aligned with evidence-based deprescribing guidelines and are written in plain-language.

3. Prudent prescribing of addictive medications

A project is being planned by the Development Centre for Primary Healthcare in Iceland (ÞÍH) to promote the prudent prescribing of addictive medications. Meetings will be held with doctors from all healthcare centres, prescribing data will be examined through Gagnasýn in the national health record (Saga) and interventions that promote prudent prescribing will be encouraged. Drug renewal procedures, tools that support tapering and development of non-pharmaceutical interventions are examples of interventions that can contribute to success.

Deprescribing information leaflets aimed at patients and caregivers are now available on the Directorate of Health website and ÞÍH.

In several parts of the heathcare system, efforts have been made to reduce prescribing of addictive medications, the results of which are promising e.g. the Primary Care Centre in Breiðholt presented their project at the Icelandic Medical Conference (Læknadagar) in March 2022. See summary.

Safe prescribing of Warfarin in hospital

At Landspítali, a project is underway to improve the way in which warfarin is prescribed and managed. Individual clinical teams currently use different methods to manage their inpatients who are receiving Warfarin.

A recent investigation into an incident revealed a number of root causes relating to the management of Warfarin: one is the lack of safety nets on the hospital electronic prescribing system (Therapy) to ensure that patients on warfarin are monitored in frequent intervals, and the other is the lack of standardisation across different wards for how patients on warfarin are managed.

A new protocol has been programmed onto the Therapy system at Landspítali whereby Warfarin is prescribed for only 3 days and after that, there is a prompt for the dose to be reviewed and re-prescribed. This was recently tested in the cardiology ward and shown to be effective.

This protocol is now being tested in the geriatric wards and will be spread to other departments and hospitals once it has been shown to work well in these settings.

Further investigations are currently being conducted about accessibility of information relating to warfarin prescriptions. Warfarin dosing information is currently not accessible to all healthcare professionals across institutions.

If a patient is being managed by an anticoagulation team outside of Landspítali, this information is not available to hospital staff when the patient is admitted. The same is true when patients are discharged from hospital and need to be cared for by a team in another healthcare setting.

Information pertaining to warfarin dosing is available in multiple systems across healthcare institutions, which are not integrated, creating a higher risk of error when patients transfer from one institution to another.

National high risk medications list for hospitals 

 A standardised high risk medications list is currently being developed jointly between Landspítali and Akureyri hospitals using the APINCHS acronym. The purpose of this is to improve the medication dispensing, preparation and administration processes on inpatient wards. Nurses on selected wards are currently being engaged to determine how this list can be utilised to improve the 6Rs (6 Rights of Medication Administration).

This page is under development.