The national inpatient medication chart: critical audit of design and performance at a tertiary hospital

To the Editor: Millar and colleagues recently described their comparison of the national inpatient medication chart (NIMC) with 14 other medication charts.1 They concluded that the NIMC contained design features that were adverse and therefore inferior to the medication chart previously used in their hospital. They also stated that the advantages expected by the Western Australian Director-General of Health in introducing the national chart were not experienced at their hospital.

Millar et al failed to mention that the NIMC underwent an extensive process of piloting and evaluation in over 30 sites across the country in a structured before-and-after study.2 Failure to recognise (i) the benefits of standardisation as medical, nursing and pharmacy staff move between sites, (ii) the opportunities for structured safe medication practice training,3 and (iii) the value of the collaborative methods used will inhibit the possibility of overcoming problems like those identified by Millar et al in future redesign processes. Millar and colleagues themselves noted that “marked heterogeneity of chart design has been abolished by the NIMC”.

The national pilot study considered the entire medication management cycle using a broad definition of medication error (“A prescribing decision or prescription writing process that results in an unintentional, significant reduction in the probability of treatment being timely and effective or increases the risk of harm, when compared with generally accepted practice”4). The NIMC was designed to reduce the risk of errors that prescribers have identified with previous charts.5 The NIMC also reduced the need for all staff to interpret unclear or incomplete prescriptions, thereby further reducing the risk of medication errors.2

We support the comments by Millar and colleagues that the process of implementing clinical practice change must involve significant buy-in and championing by clinicians. The implementation of the NIMC in Queensland recognised the importance of top-down support from senior health officials, combined with the need to increase clinicians’ awareness of risks of current systems and the need for a clear demonstration of the benefits of a revised system to bring about any substantial change in behaviour.

We understand that the Australian Commission on Safety and Quality in Health Care has established a quality assurance process which operates at jurisdictional and national levels to adjust the NIMC on the basis of issues raised. This important platform will succeed in addressing the issues raised by Millar et al provided clinicians participate in this collaborative approach to medication safety. We have a rare opportunity, in which Australia is taking a leading role, to address one of the critical safety risks facing patients today. Let us all work together and criticise constructively within a framework of collaboration.