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Interior Health Medication Management Audit

Interior Health Medication Management Audit

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Published by Joe Fries
Full report from audit of medication management practices at hospitals within the Interior Health Authority
Full report from audit of medication management practices at hospitals within the Interior Health Authority

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Published by: Joe Fries on Jul 23, 2013
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Internal Audit…Adding value across the region
File No. 11-009RDecember 24, 2012
Medication Management Audit – Acute Care
: Internal Audit and Advisory Services:
Melanie Libbrecht, Clinical Internal AuditorRob Desjardins, Senior Internal AuditorGivonna De Bruin, Corporate Director, Internal Audit
: For Action
:VP, Acute ServicesRegional Director, PharmacyChief Nursing Officer & Professional Practice LeadChief Project Officer and Corporate Director, Capital PlanningHAMACHealth Informatics Strategy Council
For Information:
Relevant Leadership TeamsPharmacy and Therapeutics CommitteeSenior Executive TeamQuality Care Committee
Distribution Limitation:
This report is for internal use only. The report may include policy advice and recommendations protectedby the Freedom of Information and Protection of Privacy Act. Copies are not to be distributed without the express written consent of the Corporate Director, Internal Audit.
Internal Audit
| Medication Management Practices Audit2
Internal Audit
| Medication Management Practices Audit3
 The Canadian Adverse Events Study published in 2004 found that as many as 24,000Canadians die annually due to preventable adverse events. Among those cases, 24% wererelated to medication or fluid administration
. A 2008 survey by the Commonwealth Fundidentified that nearly one in ten Canadians with health problems reported receiving the wrongmedication or dose from a pharmacy or hospital within the previous two years
In 2007 Health Authorities in British Columbia began implementation of the BC Patient Safetyand Learning System (PSLS). In the three years since, there have been 36,185 medicationrelated events reported across the province of BC representing 26% of all reported events. In2011, within Interior Health (IH), there were 5,306 medication related events which represents20.3% of all reported events. Experts agree that less than 10% of medication related events arereported through a voluntary reporting system.
 This audit was conducted to evaluate current medication management practices in acute careas compared to key standards, policies and leading practices. Additionally, recommendationsmade by Institute of Safe Medication Practices (ISMP) in their
Report to Vernon Jubilee Hospital(VJH), Supplemental Medication Safety Report: Identified Vulnerabilities and Recommendations(April 8, 2010), (
referred to as the ‘
ISMP VJH Report’)
were included in the audit tool todetermine whether recommendations were implemented across IH..Also, the timing of the audit (April, May 2012) provided management with a baselinemeasurement of current medication management practices prior to the implementation of the IH
Clinical Practice Standard and Procedure: Medication Management: Acute Care Nursing (July2012).
the audit assisted management with preparations for the Accreditation Canadavisit in the Fall of 2012.
In Internal Audit’s opinion, there exists a moderate to high risk of significant patient harmassociated with the current medication management practices as observed in selected medicalsurgical inpatient units.
Baker, G.R.
et al.
(2004). The Canadian Adverse Events Study: the incidence of adverse events among hospitalpatients in Canada.
Canadian Medical Association Journal, 170 (
11): 1678-1686.
Health Council of Canada. (2009).
Safer Health Care for ‘Sicker’ Canadians: International comparisons of healthcare quality and safety.
Toronto: Health Council. www.healthcouncilcanada.ca. 
Pepper, G. (1995). Errors in drug administration by nurses.
 American Journal of Health System Pharmacists, 52

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