Outcome 5.3.1

Put in place a medication management system.

All providers whose workers are involved in any part of medication management must have systems and processes that supports safe use of medicines in a way that meets state or territory law and regulations. Where the provider employs or contracts nurses, the provider must support them to meet the legal requirements of their registration and professional standards. The e-Therapeutic guidelines and AMH Aged Care Companion can support workers and registered health practitioners.

When developing and reviewing your medication management policies and procedures, check the Department of Health, Disability and Ageing’s Guiding Principles for Medication Management in residential care homes, home or community settings, or for transitions of care, as relevant to the service context.

A medication management system sets robust clinical governance for all medicines-related activities. A medication management system includes:

• a governance mechanism for managing and monitoring the medication management system. For providers that administer medication, this should be through an expert multidisciplinary group. In aged care services delivered in a residential care home, this group is called a Medication Advisory Committee (MAC).
• policies and procedures for any medication management activities workers do, including:
  • discussing the risks and benefits with the older person
  • Prescribing by appropriate registered health practitioners
  • procuring
  • dispensing
  • storing
  • administering
  • packaging
  • supplying
  • monitoring the effects of medicines and escalate and report relevant adverse events or side effects
  • assisting people to self-administer medicines.
• policies on how medicines are used and how to escalate a review for registered health practitioners and trained workers administering medicines
• standardised documentation and communication templates and protocols to make sure that you have a current and accurate record of all medicines. This list should be available to the older person and those involved in their care.
• an adverse event and incident monitoring and reporting system and processes
• clear definitions of worker roles and responsibilities for managing medicines. This needs to be in line with national and state or territory legislation, regulations and professional standards. These need to state:
  • who can administer or assist with medications in which situations
  • what competencies, qualifications and training they need
  • protocols for supervising and delegating medicine management
  • protocols for reporting medicine management concerns and escalating.

Put in place processes for documentation and information access to make sure:

• there is a standard format in your information system to document:
  • information about a person’s medicines
  • clinical reasons for their use

  • a record of their use.

    Make sure this information is documented in the provider’s information system, using the National Residential Medication Chart or similar.

• there are standard protocols to support timely communication about medicines between the older person, workers, registered health practitioners, allied health professionals and others involved in their care. This is particularly important at transitions of care.
• all changes to a person’s medicines are documented in the provider’s information system in a timely way. This includes when the changes are recommended by an external registered health practitioner or allied health professional such as the person’s GP.

Processes for safe medication assistance should make sure that:

• workers understand what medication assistance tasks support self administration, such as prompting or assisting the person to open packaging. Medication assistance doesn’t include measuring, dispensing, or administering a dose of medicine to a person or making any decisions about medicine use.
• workers have the relevant training in medication assistance, are appropriately supervised and understand:
  • how to document the assistance they provided
  • how and where to escalate any concerns or observations about a person’s medicine use
  • what to do if an older person or carer tells them they are concerned about a medicine-related issue or the older person is acutely unwell.

Processes for safe medication administration should make sure:

• the difference between medication assistance and medication administration is clear. Medication administration (giving a dose of a medicine to a person) is a complex and high-risk task that is strictly regulated under law.
• relevant registered health practitioners understand their scope of practice, roles and responsibilities for medication administration under legislation, regulations and professional standards. The provider supports them to follow these, including through clear delegation and supervision protocols for making decisions.
• registered health practitioners carry out administration in line with their scope of practice, usually registered nurses or enrolled nurses with relevant training and supervision
• depending on state or territory law and regulations, in some situations, an appropriately trained and competent delegate, such as a care worker, can perform some medication administration tasks. This must be under the supervision of a registered health practitioner.
• the older person’s swallowing capacity and tolerance to different drugs are assessed and reviewed when needed. Recommendations should be documented and followed (Outcome 5.5).
• there is timely and continuous access to prescribed medicines, especially:
  • at transitions of care
  • when urgent clinical needs arise
  • where there are changes to prescribed medicines.

In residential services, emergency stocks (‘imprest’) of a limited range of medicines approved by the Medication Advisory Committee and in line with state or territory legislation, should be used for these purposes. Support for remote access for prescribing also helps make sure there is timely and continuous access.

Processes for person-centred medication management should make sure that:

• a person who is assessed as competent and willing should be supported to administer their own medicines
• older people, their supporters and others they wish to involve are supported to take part in making informed decisions about their medicines when they want this. Any decisions about medicines need to be shared with the prescriber. Providers can support these decisions by:
• giving people an up-to-date, comprehensive and accurate medicines list
• giving people information about both non-pharmacological and pharmacological treatment options, where is this an option
• giving people information about the risks and benefits of medicines so they can give informed consent, and to support adherence to medicine treatment plans
• involving the older person, thier supporters and others they wish to involve in regular medication reviews

Outcome 5.3.2

Put in place processes for regular and as needed medication reviews.

In the medication management system described in Action 5.3.1, the regular review of each older person’s medicines by a qualified registered health practitioner is a key strategy for making sure medicines are used safely. Registered health practitioners include medical practitioners, nurse practitioners and pharmacists. In practice, ongoing reviews of a person’s medicines routinely happen as part of usual clinical practice. For example, during an appointment with a GP.

During hospital admissions, medications are often changed. Transitions of care, such as hospital discharge, are important causes for urgent medication review.

Comprehensive medication reviews by a credentialed pharmacist can also help to identify opportunities to:

• provide more optimal therapies
• identify side effects and interactions
• encourage adherence
• make sure medication is optimally administered
• deprescribe and reduce risk of harm from inappropriate polypharmacy.

Certain medicines can increase the risk of clinical incidents such as falls, and a medication review should be considered as part of a comprehensive assessment after incidents. Medication reviews should include identifying any medicines or remedies used by the older person that aren’t prescribed, such as over the counter medicines or supplements.

The following key tasks outline reasonable practice in medication reviews for providers with services that involve medication management:

• Put in place processes to support regular (at least once a year) medication review for each older person. If the registered health practitioner completing this review isn’t employed by or contracted to the provider, the provider needs to have processes to tell the registered health practitioner when there needs to be a review. This should include making sure any changes or recommendations that come from the review are documented in the person’s care and services plan and medication chart.
• Put in place processes to monitor, document and communicate the effects and side effects of prescribed medicines to the prescriber.
• Support workers and registered health practitioners to identify causes for medication review.
• Put in place processes to encourage the use of standardised processes for medication reviews. These should include:
  • documentation of available information about current (existing and newly prescribed) medicines
  • the history of medicine-related orders including oral and parenteral (ways other than oral), multiple and single dose medicines.
• Reviews should consider things like:
  • Is there a documented reason or evidence base for using the medicine?
  • Does the older person still need the medicine?
  • Is the medicine still working?
  • What risks are associated with the medicine and what monitoring is needed?
  • What risks are associated with stopping a medicine where polypharmacy is identified?
• Consider the need for modification of administered medicines if an older person is acutely unwell or their health condition has changed. This may include acute exacerbations of chronic conditions.

Outcome 5.3.3

Documenting and communicating each older person’s allergies and previous reactions to medicines is an important part of the safe and quality use of medicines. This should be recorded in the medication management system described in Action 5.3.1.

Put in place processes to document allergies and adverse reactions.

• Put in place a process to make sure workers, registered health practitioners and allied health professionals involved in the older person’s care document known medicine allergies and any adverse medicines-related event. These will often be reported by the older person themselves. Also, make sure this information is kept up to date.
• Make sure information about medicine allergies and adverse reactions is available to all registered health practitioners who prescribe, dispense or administer medicines.
• Make sure workers know how to observe and document the older person’s reactions to any medicines. This includes new allergies or side effects. Also, make sure they know how to escalate concerns to relevant registered health practitioners.

Outcome 5.3.4

As part of your medication management system (Action 5.3.1), you need to set up clear policies, procedures and processes for using high-risk medicines, in line with state or territory legislation.

High risk medicines include:

• opioids
• anticoagulants
• insulin
• psychotropic medicines, such as antipsychotics, antidepressants and anti-anxiety medicines.

These pose a higher risk to older people if used in error. They can be associated with:

• adverse drug events
• hospitalisation
• poor health-related quality of life
• death.

Put in place processes for safely using high-risk medicines.

• Put in place processes to identify, document, monitor, review and (deprescribe where appropriate) the high-risk medicines prescribed to older people in your service.
• Put in place processes to support safely using high-risk medicines for each older person prescribed them, including:
  • outlining clear roles and responsibilities for handling and storing high-risk medicines, in line with legislation
  • putting in place effective channels for communication and information sharing between those involved in the older person’s care, to monitor those taking high-risk medicines. This includes external registered health practitioners or allied health professionals such as GPs and pharmacists.
  • documenting risk of harm and necessary mitigation strategies. This helps make sure the medicine is used appropriately and the benefit for the person outweighs the risk.
  • consider planning regular medication reviews by a credentialed pharmacist to monitor how effective medications are, their adverse effects and interactions with other medications and comorbid conditions. A comorbid condition is more than one medical condition happening at the same time. This also needs to include identifying any opportunities to reduce the dose or deprescribe (Action 5.3.2).
  • supporting and facilitating the use of non-pharmacological strategies as a first line approach when appropriate. For example, when responding to changed behaviours as outlined in the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard.

Outcome 5.3.5

Adverse medicines-related events are the unintended and sometimes harmful outcome of using a medicine, vaccine or medical device. Providers should respond to these adverse events following their incident management system (Outcome 2.5).

• Providers should also report any adverse medicines-related events to the Therapeutic Goods Administration. The Therapeutic Goods Administration regulates and investigates the safety, efficacy and supply of medicines. It has a national database of medicines-related adverse events.

Put in place processes for reporting to the Therapeutic Goods Administration.

• Put in place reporting processes for all new adverse medicines-related events. Train workers and health professionals to use them. Make sure that workers and registered health practitioners know what an adverse medicines-related event is, and what their roles and responsibilities are. Depending on organisational policy, this may mean reporting to a manager or supervisor who reports issues to the Therapeutic Goods Administration.

Outcome 5.3.6

Action 5.3.6 relates to monitoring, evaluating and improving the medication management systems and processes described in Actions 5.3.1 to 5.3.5.

Put in place systems to monitor and evaluate safe and quality use of medicines.

• Develop policies, procedures and guidelines for the systematic monitoring and evaluation of medication management processes and outcomes. Make sure these are endorsed by the organisation’s medicines governance group. For example, the Medication Advisory Committee in residential aged care.

Put in place processes to monitor, review and improve medication management.

• Consider how to monitor for updates to relevant legislation and guidelines, put in place changes and evaluate your organisation’s compliance.
• Consider how to assess if your medication management system is successful in incorporating safe and quality use of medicines in the everyday care of older people.
• Consider how to monitor if your medication review processes are being performed regularly and when clinically indicated. Also, if your organisation communicates and acts on recommendations. This may include:
  • reviewing how regularly routine medication reviews happen for each older person
  • reviewing records to assess how often outcomes of reviews and plans of action are documented
  • reviewing records to assess how often follow-up actions are taken after medication reviews.
• Strategies for monitoring and measuring how effective your processes are may include:
  • reviewing how you comply with the documentation you need to do at the start of care and at transitions of care
  • asking older people and their supporters if they feel informed and involved as much as they want to be in decisions about their medicines. This includes in medication reviews.
• Strategies for assessing the safe and appropriate use of medicines may include:
  • monitoring trends in the rate, type and effect of medicines-related adverse events (such as those related to falls and those leading to hospital admission)
  • analysing incident reports and reviewing clinical records to identify unreported or under-reported medicines safety issues
  • collecting and reporting data against quality use of medicines indicators, which can include but may not be limited to those in the National Mandatory Quality Indicator Program.
• Based on the outcomes of your monitoring, identify and put in place quality improvement strategies for medication management. Report the outcomes of your quality improvements to:
  • the governing body
  • workers
  • older people
  • other relevant organisations depending on the service context.