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Ha. DSCO Trends in medication related complaints to the Health Disability Services Complaints Office Ha. DSCO Trends in medication related complaints to the Health Disability Services Complaints Office 2009 -2013 Linley Anne Donaldson, Director Dr Eric Khong, Medical Officer Sarah D’Andrea, Research & Policy Officer Dr Ann Choong, Medical Officer Prof Moira Sim, Medical Officer Tuesday 24 September 2013

Ha. DSCO About Ha. DSCO § Ha. DSCO is an independent statutory authority established Ha. DSCO About Ha. DSCO § Ha. DSCO is an independent statutory authority established in 1996. § Ha. DSCO’s services enable the agency to identify needs for service improvements and make recommendations to enhance health and disability service delivery in WA.

Ha. DSCO Functions of the Director § As set out in the Health and Ha. DSCO Functions of the Director § As set out in the Health and Disability Services (Complaints) Act 1995: - to deal with complaints - in collaboration with groups of providers or groups of users or both, to review and identify the causes of complaints and to suggest ways of removing and minimising those causes and bringing them to the notice of the public - to take steps to bring to the notice of users and providers details of complaints procedures - to assist providers in developing and improving complaints procedures and training of staff in handling complaints - with the approval of the Minister, to inquire into broader issues of health care arising from complaints received - to publish work of the Office from time to time - to provide advice generally on any matter relating to complaints - to provide advice to users on the making of complaints to registration boards and other avenues available for dealing with complaints - any other function conferred on the Director by the Act or another written law.

Ha. DSCO Objective § To examine data and trends regarding medication related complaints received Ha. DSCO Objective § To examine data and trends regarding medication related complaints received by Ha. DSCO from 2009 to 2013. § Understanding the nature of these complaints and the trends could help healthcare providers and policy makers to formulate strategies to reduce the prevalence of these complaints.

Ha. DSCO Methodology Medication related complaints received by Ha. DSCO are categorised into four Ha. DSCO Methodology Medication related complaints received by Ha. DSCO are categorised into four subcategories: 1. Administering; 2. Dispensing; 3. Prescribing and 4. the Supply, Security and Storage of medication. Statistical data for each category was analysed for trends. Selected case studies will be used to illustrate the findings.

Ha. DSCO Results 9, 219 complaints were received from 2009 -2013. There were 542 Ha. DSCO Results 9, 219 complaints were received from 2009 -2013. There were 542 (5. 8%) medication related complaints. 15% 49% 14%

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Ha. DSCO Complaint: Administering Case Example: Mrs A with hypocalcemia v 45 year old Ha. DSCO Complaint: Administering Case Example: Mrs A with hypocalcemia v 45 year old woman who had a thyroidectomy for hyperthyroidism in a private hospital. Her parathyroid glands were also removed. v. Mrs A was prescribed calcium tablets post-op, but the ward staff did not give them to her for 18 hours. v. She was discharged home on Day 3 post-op and presented to the private hospital’s ED on Day 4 for symptoms of hypocalcemia eg. tetany and weakness of her limb muscles.

Ha. DSCO Complaint: Administering Case Example: Mrs A with Hypocalcemia v. In the ED, Ha. DSCO Complaint: Administering Case Example: Mrs A with Hypocalcemia v. In the ED, she was frightened, frustrated and had difficulty speaking. She was “told off” by the ED staff for being loud and rude. v. Mrs A was admitted and given IV calcitriol. v. She made a complaint to Ha. DSCO about being discharged with low calcium levels, not receiving calcium in a timely manner in hospital and the way she was treated in ED. v. This case went to conciliation.

Ha. DSCO Complaint: Administering Case Example: Mrs A with Hypocalcemia v. Outcomes of conciliation Ha. DSCO Complaint: Administering Case Example: Mrs A with Hypocalcemia v. Outcomes of conciliation v. Apologies v. The ED staff would have further education in recognising and managing hypocalcemia. v. Refund of out of pocket expenses, approx. $400. v. Goodwill payment of $5000 in recognition of stress and trauma.

Ha. DSCO Huntington's disease was discovered by an American, George Huntington in 1872, at Ha. DSCO Huntington's disease was discovered by an American, George Huntington in 1872, at the age of 22. HD is a Hereditary Movement Disorder.

Ha. DSCO Complaint: Dispensing Case Example: Mr D given incorrect medication v. Mr D Ha. DSCO Complaint: Dispensing Case Example: Mr D given incorrect medication v. Mr D is a 77 year old man living in a nursing home. He receives his medication in sachets. v. His wife complained to Ha. DSCO that her husband had been given the wrong medication on 3 occasions. v. He was been prescribed Tetrabenazine 25 mg (for Huntington’s Disease), but the pharmacy dispensed Terbinafine 250 mg (anti-fungal). v. Mr D was taken to hospital after his wife detected the error after he had 5 doses that week.

Ha. DSCO Tetrabenazine Terbinafine Ha. DSCO Tetrabenazine Terbinafine

Ha. DSCO Complaint: Dispensing Case Example: Mr D given incorrect medication v. Investigation revealed Ha. DSCO Complaint: Dispensing Case Example: Mr D given incorrect medication v. Investigation revealed that at the pharmacy: v. Many tablets were packed via automated packaging. v. For uncommon medications, a packing technician is instructed by information on a computer screen and packs tablets into sachets. v. A pharmacist checks the medication.

Ha. DSCO Complaint: Dispensing Case Example: Mr D given incorrect medication v. What went Ha. DSCO Complaint: Dispensing Case Example: Mr D given incorrect medication v. What went wrong? v. The technician packed incorrect tablets. v. The pharmacist did not pick up the error. v. The aged care facility did notice the error. v. What did the pharmacy do as a result of this? v. Additional training of technicians. v. Checks by two pharmacists. v. Posters on the wall in the production room of medications commonly mistaken for each other.

Ha. DSCO Complaint: Dispensing Case Example: Mr D given incorrect medication v. The pharmacy Ha. DSCO Complaint: Dispensing Case Example: Mr D given incorrect medication v. The pharmacy was very cooperative and concerned this happened. v. They contacted the complainants by phone and written correspondence to offer apologies and explanations as to how the pharmacy would address the problem.

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Ha. DSCO Complaint: Prescribing Case Example: Mr M with low testosterone v 55 year Ha. DSCO Complaint: Prescribing Case Example: Mr M with low testosterone v 55 year old man with low testosterone. v. His wife asked him to get treatment for “grumpy man syndrome” ! v. Had a phone consultation with someone (not a doctor) from a men’s health organisation (X). v. He committed to a 12 month program @ $175 per mth. v. His was prescribed bio-identical testosterone after completing blood tests requested by a doctor at X. Levels were at the lower range of normal.

Ha. DSCO Complaint: Prescribing Case Example: Mr M with low testosterone v. His wife Ha. DSCO Complaint: Prescribing Case Example: Mr M with low testosterone v. His wife is a nutritionist and was concerned that he was not monitored by a regular doctor, and most importantly was not improving ! v. She wanted X to refund the monies. v. X defended their program and refused to refund monies. v. The complainant took her complaint to the ACCC.

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Ha. DSCO Complaint: Supply/ Security/ Storage Case Example: Ms R on antipsychotics in prison Ha. DSCO Complaint: Supply/ Security/ Storage Case Example: Ms R on antipsychotics in prison v. A 40 year old woman at Bandyup prison was on a number of medications including, paroxetine, lithium carbonate, quetiapine, carbemazepine and thyroxine. v. She was transferred to Greenough prison in Geraldton, and was not dispensed her medication. v. She complained to Ha. DSCO that she did not receive her medication for over 24 hours.

Ha. DSCO Complaint: Supply/ Security/ Storage Case Example: Ms R on antipsychotics in prison Ha. DSCO Complaint: Supply/ Security/ Storage Case Example: Ms R on antipsychotics in prison v. On investigation at Ha. DSCO, her medication chart recorded that she was prescribed 900 mg nocte of Seroquel v. Seroquel 200 mg x 2 v. Seroquel XR 200 mg v. Seroquel XR 300 mg. v. It is custodial policy that all medication is crushed at night in Prisons.

Ha. DSCO Analysis of cases in each category discovered recurrent themes relevant to each Ha. DSCO Analysis of cases in each category discovered recurrent themes relevant to each complaint – 1. Communication and information issues 2. System issues

Ha. DSCO Questions? Ha. DSCO Questions?