BOPDHB Checkup December 2018 | Page 21

Pharmacists Lucy Wong and Tamsin Willis with their awards from NZHPA Conference 2018. BOPDHB Pharmacy team at the conference from left: Donna Gardiner, Cindy Mortimer, Lucy Wong, Tamsin Willis and Adele Harrex. Success for pharmacists at national conference I’m home now what do I do with my medication? A team led by Tauranga Hospital Pharmacist Tamsin Willis with Ashleigh Eaden and Kelly Hiha was awarded the Best Poster by a Technician sponsored by NZHPA. This Health Quality Safety Commission (HQSC) co-design project worked directly with consumers to identify and improve patient understanding of medication information at discharge. Tauranga Hospital Pharmacist Adele Harrex presented on two projects about utilising a Pharmacist Prescriber’s advanced skills There are significant opportunities to prescribe in a general medical team, in keeping with local policy. Table 1: Prescriptions items written in a three month period (April – Jun 2018) Prescription type COPD VTE Team plan Medicines reconciliation error error Atrial Prescription fibrill prevalent ation (AF) Defined area of practice Original Original 15 51 Expanded 8 is becoming in our agein Rechart Discharge Number of items 10 25 Expanded Expanded Expanded more Expanded 4 8 Example Clinical review, stopped unnecessary inhaler Patient with previous VTE, high risk, so enoxaparin prescribed Nystatin documented for painful oral thrush (palliative patient), not yet prescribed Usual insulin omitted for mental health patient rd, Tauran Prednisone recharted at 20mg inadvertently, ga The risin g tide o Can we st f IV Iron Infusions. em the fl ow? instead of 5mg Results No house officer available in ward Prescription written / faxed to community while g population patients and This digita and their famil l resou information ies are keen Limitation prescription team still rce on round, facilitating faster discharge has been least 20 patie about this for shown to s / its treatm condition nts. The clinic at Total 121 ent. and often still Centred Car Patient al pharm invol funded antic There are now seve patient watc ved in the education acist is ral oagulant e options for that medical, nursing and pharmacy Anticoagu Survey results demonstrate staff hes have confidence in pharmacist Investigate with the Pharmacy Council NZ lation educ Patient centr patients. visits to answ the clip, then the process e.g. ation commented prescribing. Doctors on the ability to pick up errors and that pharmacist pharm prescribers ed communica er feel (PCNZ) who set the prescriber competencies, undertake is a task regul ques acist have tions and n by clinic rapport to understan tion requires arly value the accessibility chec al pharm be developed ding. planned good knowledge of medicines. Nurses of the pharmacist on the ward. My prescribing k University of Otago academic, and Clinical Phar acist to make a macy techn their story have s. We , and patie digita across . Just beca ician of a junior doctor. ated with this skills nts to tell carry areas of practice with alloc similar / safety to that Lead for Medicine BOPDHB, if a local l resou to time on 1 support use educ now rce more inform video to patie wards may s that Gardiner,D to ation help 1 ation Tau proce , doesn’t mean we give patients provide inform ran show the policy change would provide appropriate nts and ss and poten ; Stre ga er Hos answ Example from survey data to the ward pharm ation comments they ‘buy tially pita or l BOPDH idea, or K 1 ; Bok questions will be et, to a wider clinical governance for wider prescribing. adhe or, A in’ 2 to the acist. rent patient group refer chec to a new B, klist ran Tau approach 2 Feedback . Intr medicine. A policy change was written and approved What concerns do you have? Do you have confidence in pharmacist to Auc A education odu majo patient centr ga. been large ctio klan is not entire by the Hospital Medicines Committee, then n of – has ed. prescribers? ly rity posit “Nil it’s the future” Registrar. Howe Anaemia ly sity patie ver, these d Uni used as a ver during pregn ive with the nts gaini risk of than video incorporated into my PCNZ Prescribing tool to help of their antic is assoc , Aucklan ng good ancy “more likely to pick up prescribing error a ture prema unde iated patients make s can be decisions oagu delive with rstan d. What are the advantages of a pharmacist lant. Res ry increa ding and Practice Plan. This enabled me to prescribe Aim doctor who is rushing” Registrar. Early interventions abou Video is broke four sectio ults medi 27 wome t anticoagu sed maternal/ch their own ns: aimed ild morta n down into AF, dabig anaemia in prescriber as part of the cine in partic at preve lity. MDT? n completed lation, and which widely, in collaboration with the clinical team. dabigatran atran nting iron pregn versu ular, will the suit To produce “less likely to have a discrepancy between deficie oral iron supple ancy includ survey and ncy s warfa rivaro e to ry advic dietar “easy talk y educa to, convenience of being on the rin, Dieta them best. Pres a brief, free, xaba Many provi menta e: patients n. Rivar ng tion tion adverse effects resource, admission to be cribed Iron and oxaban but the results like the digita discharge” officer. e, digita House most ward, able to check” Nurse. that would and onlin are double is ● 21 (78%) wome suppleme and their resou limited watch l rce l impac by ed nature of provi families with nts wher section so n receiv t on comp Intravenous e they can the ● 22 (80%) women were ed dietar liance. far. increasing own information de patients and their iron can be y advice take red meat inform Updated BOP Policy: Health options for given presc failed or is such contr and ation utilised once about antic as ol of their supplements but green , watc riptions for inapp ● the treatm leafy 16(60 oral therap only 18 (66%) h veget oagulation at a time ropriate i.e. it more %) implem due to previo iron before birth ables. than once ent of AF. y has not tolera ented that had them suits us experience is too short of their pregn dietar ted, or the Professionals Roles and them. , and filled, mainly y chang Bay of for oral with period ancy. es ● Implementing the Role Responsibilities Pharmacist – Designated Prescriber Prescribing within an individual pharmacists defined area of practice, submitted to PCNZ Method Narrow defined area of practice I’m home now with my m – what do I do edication ? Plenty One area I can prescribe in, is VTE prophylaxis. Do you I can prescribe medicines on discharge. Do you have confidence therapy to take effect Side effect markedly VTE DHB use of IV have confidence in a pharmacist prescriber completing in a pharmacist prescriber doing iron . this? increased s/Issues with diet: in an effort in pregnancy has blood transf assessment and prescribing enoxaparin if appropriate? Cost to Resources usions postn atally. 9 reduc 9 e the 8 need for 7 8 6 7 over the cours e At 32 weeks gestation starte only 9 side effect s. d on a therap (33%) wome Willis T, Ead eutic dose n of quality ● Only 12 of elemental had been (37%) iron. and 3 wome red meat was a barrie en A and 200 mg daily) were prescribed Hiha K, n a treatment hyperemes could not eat adequ r for 1 participant elemental Contex dose (100- their Bay of of Ple is or reduc ate amou pregnancy. at any stage nty iron nts due to ed appet t Dis trict Health Board, Tau ranga BOP DHB Experience Patient Sur (Sep 2016 vey Measurem - Sep 2017 ent of imp ) rovement ite. during OTC already 5 BOPDHB allows pharmacists with Expanded 4 Q4: Number of Supp lements revie able onlin What’s my respondants 3 prescribing authorisation to: area of wed to ensu avail 4 Q1: Number of e were Prescribed Range ● medic 2 re that ine called 13 (48%) • Prescribe admission medicines, if they prescribing To investigate respondants 3 elemental and how do this resou Average there was iron dose/da 1 Average gestatio rce. I take it? 1 wome ? n What is it for? When have been prescribed by a doctor within the after policy 2 y a gap for 30-265 mg given to wome the advice and n Started made my supple What were given Treatment ments 0 advice advice routin Leaflets, 82.7 mg websites infusions 1 last 6 months change dose ent Sometimes No, this to is the n who receiv Yes, treatm es purch can be medications that chang always Mostly have been regarding iron in the anten 200 mg daily) (100- and the 26 weeks ely given 0 are quest ed IV iron medical teams ● 14 • Amend prescriptions following medicines ased over while in hospi course atal we hope to women took at Tauranga by Yes, always duration ions health Sometimes No, this is the 2-27 weeks clinic Mostly responsibility the count al pharm identify oppor period. From this reconciliation OTC supple tal? These care profes medical teams Hospital, 8 weeks er. elemental Subtherapeutic information assume a patien acist tunitie ments with responsibility sionals freque s treat wome were exam the key conc • Prescribe in consultation with the clinical iron equiva 24 weeks dose (<100 ined and and reduc n with iron deficiency s to better prevent and discharged Side t has answ ntly a total daily lent of 10 epts ident mg daily) ers team to course before they -48mg. into effect 1-15 weeks staff mem e the numb ified. Actor anaemia the comm We did a s/Issu Patient expe duration in pregnancy The are 6.8 weeks • Re-prescribe medicines on charts er of IV iron bers produ small test unity, s on and I can prescribe medicines admission, or amend charts after es with but OTC 2017 OTC rience - often suppl of change infusions ced draft patients on 28 weeks were edite HQSC • Prescribe medicines on discharge that they don’t. medicatio medicines reconciliation. Do you have confidence in a pharmacist required. supple ements: in selected Natio ments Side video one d by the has highli nal Patien Patient expe s that n effect have been reviewed by the clinical team, or (n=12 s/Issu high were t very surgical ward general medical proje doing ghted woman prescriber this? Exper 1) es with presc versions of 50 ct team rience - a report well lack of ing ience and one gener risk documented as part of the discharge plan tolera medication at Tauranga . The initia Surve side effec patien the videos ted with any side 11 (61%) ribed y only 45 t under eleme suppl side ntal al ts Hospital. l effect wome (n=49 in patient notes. selection stand were Pharm effect emen 1 12 s, iron n ing possib ) s disch who then 5 6 Aim Conclusion ts: acy Techn and conte of ly due to 2 supplements took presc of healthcare arge. and self-m tested on Me nt. Cost icians were Disch anage a barrie the low ribed oral of these majority of arge r paper a ment on 10 feedback. profe thod A retros Collaborative prescribing for many. towards utilised to preparation iron of these wome reported experiencin ssionals for individualise work e.g. within clinical teams health Subseque prepare is often 3 month care profes g direct 8 pective quest direct nt versi s of ed Spato s is high designed on patients the side effect n, discontinued their side effects. 7(39% and remove discontinue d patient medication c the sionals and ne $174. works ionna in a variety distributed be under saving ) patient and feedb 6 ons were trialle received IV ire was of inpatient to settings, course as is not ards, s. d or expired stood by the to wome described d iron during a result of medication Q2: Number of who had their medic Only 3 wome calls, and utilises Bloo pharmacist skills patient. pregnancy time, n phone s. On respondants 4 ation card We worke n took anyth and target ds as “magical”. e d with comm ed: ing to relieve to optimise medicines for patients. Feedback on was uploa ● Dietary advice on the hosp 2 Fee : dba high risk pa unity provid the sympt what advice Haemoglob ital intran ded when they ck they from tients to Me ers and referr oms. colleagues is largely positive and in there et site. Quantitative prescribing statistics were 0 (Hb): implemented from were care. We sta ed given Yes, always Mostly Sometimes No, this is the ff governance liaised with dwise or their GP and Ferritin: any chang and Pla in ien ● Initial if/ pat ● OTC is clinical place at BOPDHB medical teams nne recorded and qualitative feedback was for on community antenatal for es. ensure medic and Presc d responsibility cha ts blood pharmacies going ribed Iron nge of s were taken for - Which avera ● 13 (48%) future pharmacist prescribers. the The benefits obtained from members of the clinical team Supplemen on discharge, ation changes were to ge initial supplements all women of the wome • To impro Hb being ts: followed throug and comp team your Con were with 114 g/L. Dose, and 15 weeks n had ferritin ● ve a pharmacist prescriber in a general medical “You I can prescribe medicines based on the - team plan freque e.g. from by way of a survey of 12 health professionals broug 6(22% the liance clu h qualit ht , 8 (29%) aids kept sion ncy, timing fantastic or y of be on all receive about ) would job presc inform of which were taken at or before ribed. clinical up to date. consid supple in ments notes or verbal advice. Do you have confidence a pharmacist mcg/L theref and durati ation bookin Feedback: setting, other setting with support ered that have done a (92% response rate). PDSA cycles Patient were used their Anticoagulation education g. the anaem on of al, or patient already below 2. We utilise medic patien ore consid Test of chan ic from ations. prescriber doing this? ts initial - Side effect taken. they are profession We • could this d the Impro ered have study. the deficie ge ve videos of the clinical team be applied to many 30 BOP 4 to refine the data collection form, and when produced s/ barriers communica (High risk nt for the DHB survey (Sept understand - look to ent to treatm dealt with friendly a useful digita tion comp purpose of patients) that professiona 9 2016 – Sept patient experience ● All ferritin them. and easy en New Zealand n = 19 developing the survey. limen ls and patien betwe transit.” health keywo the l resou in how they hospitals. ts 8 2017), using care levels taken them & rds pharm using rce to ‘medi ● can ts Blood about • Improve pa acist educ reach patie mcg/L. cation’ (n=12 after 21 weeks the s were forward 7 medic (n=49 ation ations tient unders ) to graph nts 1) and ‘side Transit lounge nurse , and were that . migh 6 - Initial and investigated get tandin their medic the overa much effect’ below 30 t otherwise either positi g and inform subsequent for each respondent ll 5 ations patien confi ation t experience ve or negat before not dence . particular). antenatal now going at in all. This 4 available Conclu ive. Q3: Number of bloods (Hb as home onlin Acknowledgements: . - Iron studie sio respondants Discharge 3 in e at BOPDHB resource is in Rx Review the n s (Ferritin). proce While Contact: [email protected] 2 Patient Educatio ss of dietar • 73 % at least and we Adele Print, “I’m University publi y shing and OTC n maternity for full publi supple pleas of Otago 1 that intervention 1 clinical Bay of Plenty District Health Board (BOPDHB) • 68 % received it on the intern are carers appea Referrals you ed School use. mentary advice • Avg. 2.91 0 In add of Pharmacy • 47 % medicatio education well tolera rs to c be et this study, the major from Yes, always Mostly Sometimes No, this is the • 21 % referred interventions/patien riva were Me well implem n card ted, ab lat 40 40 35 35 30 30 25 20 25 Positive Negative 5 20 15 10 15 10 0 5 ack obtained questionn aire. The via a Measuring the Improvement final versi for use The paper looked at an innovative pharmacist discharge service collaborating with health care professionals at the point of discharge. The service ensuring the correct medication prescription, patient education and adherence support including seamless transfer back to community pharmacy. Results Developm ent of a di educatio gital reso n on Antic urce for pa oagulatio Author: Har tient rex A, Gar n for Atria dner A, Mc Kenzie E, l Fibrillat Bay of Ple Backgroun nty Distric ion d t Health Boa The pharmacist prescriber course is demanding post-graduate certificate, made easier by starting with a narrow ‘defined area of practice.’ BOPDHB is a medium sized hospital where most pharmacists are ‘generalists’ so the ability to prescribe more widely has potential benefits for patients. The hospital inpatient setting provides a collaborative and supportive environment that facilitates a new prescriber being able to prescribe more widely. Whakatane Hospital Pharmacist Lucy Wong was awarded the Best Paper in Medication Safety/Innovation sponsored by Health Quality Safety Commission. Author: Harrex A, Bay of Plenty District Health Board, Tauranga Background Faster equals Smarter Better Safer? Integration of a Pharmacist Prescriber Role into a General Medical Team 0 Provision of medicines information Circle the number that best matches the following questions: How well did this video help you or your family/whanau what the medicine understand is used for? Poorly 1 Excellent 2 3 4 5 Did the structure of the presentation (the order in which information was presented) the make sense to you? Confusing 1 Easy to follow 2 3 4 5 Was the visual information helpful in aiding understanding spoken content? of the Not helpful 1 Beneficial 2 3 4 5 Has this presentation made you feel comfortable medication? taking this new Not at all 1 Very comfortable 2 3 4 5 Was the online format helpful to learn about Not at all this new medication? 1 Very helpful 2 3 4 5 Did you find any part(s) of the video confusing? Not at all 1 2 3 4 Patient feedb ack form Experienced side effect(s) Re-admit or GP visit needed Privacy concerns Please answer the following questions and discuss comments/concerns with the pharmacist Do you know when to take your medicine? ⃝ Yes ⃝ No Do you know the side effects to watch out for? ⃝ Yes ⃝ No Do you know where to look or who to talk to if you want information? more ⃝ Yes ⃝ No Do you know when to go and see your GP? ⃝ Yes ⃝ No Do you think this video will be beneficial for other patients on this medication? starting ⃝ Yes ⃝ No medical teams Would you use this video at home to answer any questions responsibility help others understand or to this medication? ⃝ Yes ⃝ No After viewing this presentation did you still want to discuss medication with a the pharmacist? ⃝ Yes ⃝ No Pharmacist to complete Questions asked by the patient thods the amou General rox Teams le BOPDHB e sta Medical ented and nt of iron ge as aban in, to deficiency requires required to prescr Team November 2018 Nursing BOPDHB large food treat it Ward 2C at WBOP treatment ity doses of oral of the women did Com not receiv mu iron iron daily) t • (Max. 7) • 31% scripts prepared by volumes of is go and supple a e pharmacis iron Pha I was given ibe and those nity (100-200mg of t OTC Supp ing worked with rma that did had elemental lots of side effect Cons d more We Ackn ments This make relatively expensive cy s, Sur helpfu leme owle . dgem ially Taura a high occur and to be financ l inform most of vey ult nts challe s it impractical nga nging taken ation which were Hosp for relief medic ents: mo tal rence of used about during ant cardi hospi ital many Dr Dean re. and comm and ward in conjun my new not ation. The ” staff, n and unity Bodd preg medic olo part as ction pharm ington wome nanc ine.” given yed short cours treated with any gist of oral with should be 3. We surve acies the iron. adequate treatm and the cardio , and es that result Patient startin y ent Prescribe time pharm doses Partn HB programme HQSC BOPD unity Weste studie comm to have logy ts of presc ers Pharmacists patien ed g r “I felt that • “Magical” • 26 % complianc e aids • 5 % expired meds removed Medwise/GP • 32 % liaised communit with y pharmacy in Care Co-D did not Feedback rn Bay s sugge the desire ribed team acies (Septembe of Plenty Ferriti st that Survey esign Rennie, Nitin n is a Keryn r 2017 . taking oral in the d effect. Recen clear July 2018) • All may and – very iron every t We surveyed hospi respo increa pending iron absor Sally Llewe usefu Scari . a and Raew ndent se secon tal prescribers side l early of change (n wante ption s. s This Multi- listed on effect d all and reduce the incide d day involved in early along deficiency llyn, tor of yn Ridley (actor = 5). All do anaem Media indica utilised during those ia and ation detail Desig s) the disch could be medic on discharg the with Hb to ctors felt th consid s nce of stopped, unable to arge resource periods are ensure adequ should be ner e was “high at pharmaci test tolera presc an option monit “It is reassuring that ription ered developmen te highe enable dose Cont the servic trialled i.e. new, for ate oral treatm ored act: more increa r daily None in a timely t. e again for ly beneficial”, and would st input wome sed, response. doses decreased. • Comm n to comp I can advise the patient or their ent mann how unity adele.harre priorit respondent to deal lete oral therap and may pharm with acy x@bopdhb er and monitored for s agreed that ised high-risk patien use side family member to watch, or re-watch the staff frustra effect and ted” y. Advice Bay of Plent felt .govt. ensur to s ts. All at “stres be all medication the on nz about ing the detailed on them point send clarify y District and of presc woma get home, I just We captu video once they Floradix ing n is aware sed changes need adequate a discharge red patien Health Board ribing (1mg/ml • 4/11 stay, high rge presc therapy, may discha of the ription prescription pharmacies t and staff patients risk patien elemental when relating get impor s. tance (BOPDHB) the link. Especially and iron) well for long experience to our curren provid ts reduc help decre (i.e. of and ed medication reduce non new, stopp ased). Man a further e the need for data t discharge worked with discharged quickly.” ed, increa compliance forma y prescriber IV therapy. cards proce patients to provide medic 6/11 pharmacies sed, t when routin s have now were willing , Pharmacist pharmacy identify areas ss. We then ation adap ely could writing cards ted this to was availa Frequency OTC and Prescrib in which make impro if adequate discharge ble. of side effec prescription vements. ed Oral Iron For IT system 1. Baseline 30 Gestation s. patient narr ts from Pres cribe Prescribed atives lacked under r feedback: oral iron standing of identified patients “I feel reass condition, 25 27 ured and felt uninv the treatment of their Novembe previous meds that I haven’t misse r 2018 They highli olved in their 11 completed Lack ght d off of official / discrepanci in inconsistent care. identified” that can 20 exist the difference in “Lack of detail es have been None guidelines practice. The literacy levels with betwe is result the the most production en patien professiona Nausea ts and health “All inform impro following comm of guidelines s “Confident, althou included proble ls. would m”. ation shoul ving the succe on care gh I would go along 15 medication d be visible Constipation know what the need ss way doubl of >100mg elemental to section myse e check reconciliatio iron therap for IV iron: , as oral from prescribed iron daily Iron exactly what lf” n has alread this helps Stomach upset us y and reduc supplements “I think the (Treatment dose) e is expec y happened, to ● Ensur 1 - 99 mg elemental work 10 ted studie e iron iron daily from Prescribed going s forwa Headache and I aways is great, partic that the pharmacists Iron supplements are done rds”. at subsequent (medications bring them in ularly med are 10-60mg Elemental booking and Heartburn antenatal review of ) but they Iron rec and const doing from OTC supplements daily it or anythi bloods. medications didn’t look 5 ● Prescribe ant ng. What at prescribed” Loose dark betwe stools was just what they were giving me to treat deficie en 100-200 mg they wante of elemental ncy. d. …they didn’t 0 iron daily ● Inform explain why Ferritin Leve Pre pregnancy changes were wome 1- 8 weeks the 120 9-16 weeks medic ls happening. 17-24 weeks ation taking tablet n on how to avoid/ (hypoglycaem 25-32 weeks And I Gestation treat didn’t We used get struck 33-40 weeks ic) like 100 the every ine s with food, using laxativ side effects e.g. here (in hospit this, like I get struck improveme basel secon data d day es, lower to identi better fy than in al). I just conk nt. 80 doses key nothin areas out. ● Follow g. for Re-admitted We identifie up bloods 60 Elderly Patien 4-6 weeks Working togeth d a number after initiati t. 1stFerritin of resource Monthly supply er with patien level (mcg/L) • Lack of ng oral therap outcome of Ferinject issues: 40 to Maternity ts towards availability has y. a shared of pharmacists on wards. Seeing health positively changed Interim Ferritin 20 our practi and techn (mcg/L) ce. icians invaluable. care from a patien • Limited t’s viewpoint We 0 IT infrastructu “I don patient increa feel taking a little is Ferritin prior re / paper 0 to infusion extra • Community (vanco ’t thin based syste 10 (mcg/L) Footnote health outco ses patient involvemen time with a 20 mycin k that me pharmacy ms. 30 mes. Draft guidelines card syste t and impro need a suitab ) Gestation 40 were (weeks) importa was one dication implemented in BOPDHB ves Conta m. le medic ct: in of ation August 2017 Donna.gard nt one the ver as a result Sever of the spike iner@BOPD s…” in IV iron y use. Key theme Dispensing Bay of Plent HB.govt.nz couldn e C.Diff figures would s that emerg suggest that y Distri pat their ’t acc ct Healt presence ed through has made a significant ess ient who impact the captu h Board (BOP on reducing antibio after re phase DHB) the need for IV hou : Confusing 5 Patient suggestions after viewing the for further improvement: presentation: rivaroxaban Elevit pregnan cy (60mg elemental iron) Engage/Ca pture Key Sugges tions The conference focused on the role of both hospital and community pharmacists working with other health professionals to improve the quality and safety of patient care. Tauranga Hospital Pharmacist Donna Gardner presented on a project identifying opportunities to improve the effectiveness of oral iron therapy and reduce the need for intravenous iron for pregnant women. Understan d Lessons learnt 50 45 40 35 30 Putting the WELL in Wellington was the theme of this year’s NZ Hospital Pharmacists’ Association (NZHPA) Conference hosted in the capital last month. The BOPDHB Pharmacy team was well presented and received two awards. in the inpatient medical setting and developing online educational packages for anticoagulants. The latter has also sparked interest for national use. By Cindy Mortimer, Manager, Pharmacy team. 25 20 15 Vials Issued 10 5 0 Month of issue rs. tics For furthe r inform ation see https://www. full case study availa Resources/A hqsc.govt.nz/assets ble at: /Consu -pharmacy-se rvice-on-disc mer-Engagement/ harge-BOP-J Acknowled un-2018.pdf gements: Byrne N (Consumer), L (Ko Awate Health Quality & Safety BOP DHB a), BOP DHB Tauran Commission Quality and ga , Maher Patient Safety Hospital Pharmacy Department, . Contact: Tamsin.willis@ iron. Confused Unprepared Unanswere d Questions “My neighbou r advised me what to do” “Shipped me like cargo” out .nz Assumptions / Lack of detail Novembe r 2018 Anticoagulat ion: What is the plan with aspirin? Paper based systems Free text / no decisio n support Systems bopdhb.govt When was dose given? the last Next due? Medication cha nges / need to synchronise with existing meds Image from: https://ww w.rwjf.org /en/library source=H ealth+Navigator+N /infographics/visual CAMPAIG N_2018_05_29_06 ewsletters&utm_ca izing-health-equity f012774c .html?utm mpaign=f _59_COP 31-12154 _ 012774c3 Y_01&utm 4193 1-EMAIL_ _medium =email&u tm_term= 0_2e5d84 / Delays Clunky Novembe r 2018 Wasted time Frustrated References: 1 2 9d0b- Questions that featured URL: www.hqsc.go in the Health Quality & vt.nz/our- Safety Commiss programm Health Quality es/patient-safety-w ion’s Patient & Safety Commiss Safety Week Survey. W eek. ellington: 2017. ion. partners-in-care/pu Health Quality & S 2017. Raising the Bar on the afety Com blications National Patient mission. URL: ww -and-reso urces/pub Experience w.hqsc.go lication/2927. vt.nz/our- programm es/ 21