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

In reply: It is understandable that the designers of the national inpatient medication chart (NIMC) should wish to defend it against criticism, especially after 5 or more years of hard work and the major administrative achievement represented by the “top-down” implementation. It is regrettable that the chart at the centre of this otherwise admirable activity turns out to have significant weaknesses compared with the previous medication chart used at Royal Perth Hospital, and that the designers acknowledge this only obliquely by allowing for “future redesign”. Rather, they emphasise secondary outputs such as cross-border familiarity (which we discussed in our article1), “training in structured safe medication practice”, and “collaborative methods”. These supposed advantages are but small crumbs of comfort compared with the imposition of an unsatisfactory chart, loss of local autonomy and increased hazard for patients. There is no evidence that the NIMC has decreased medication errors, defined in relation to patient harm. There was indeed a pilot study, and we referred to it in two different contexts in our paper, but it assessed the chart on the basis of unsatisfactory process-based criteria similar to those employed after the chart was implemented. Perhaps a better indication of the problems of the pilot chart lies in the hundreds of suggested changes made from pilot sites to the NIMC Oversight Committee.2

We note that Coombes and colleagues do not dispute our scientific findings or the design faults we described. Their response repeats unverified claims of benefit that we discussed in our article, and seeks to reassure readers that a process is in place to “adjust the NIMC on the basis of issues raised”, thus acknowledging that “issues” exist. However, readers should be aware that the process referred to is subject to a set of ground-rules which prohibit changes to several design aspects of the chart that we criticised (eg, the block design of the pro re nata [PRN] section).3 Thus, the possibility that the NIMC will be substantially improved is remote. A more likely outcome is that Australia will be left with a chart that satisfies the superficial attraction of national standardisation but contains significant design flaws which represent a hazard to patients. A better approach would be to agree on binding national standard design elements and to restore to individual hospitals or health areas the right to design their own charts within these constraints — “think globally, act locally”.4