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We hope to continue working closely with each DPET to provide support and develop resources that will assist you in this vital role. Here is an update on current items of interest. If you would like further information or to submit items for discussion, please contact Craig Bingham, Prevocational Program Coordinator at IMET, cbingham@imet.health.nsw.gov.au(9844 6511).
— Dr Roslyn Crampton, Chair, Prevocational Training Council
Prevocational Progress Review Forms
Interactive learning module
IMET has developed an e-learning module to help JMOs, JMO Managers, Term Supervisors, and DPETs learn more about using the Progress Review Forms. The module takes about 10–15 minutes to complete and provides a good introduction to the forms. Click here to try it now!
Fatal prescribing error
Allopurinol and azathioprine are medications with dangerous interactions. Late last year the Root Cause Analysis Review Group of the Clinical Excellence Commission wrote to IMET about a case in which this drug interaction contributed to a patient’s death. Here is their report of the case, with several important lessons about safe prescribing.
A Serious and Known Drug Interaction
Sequence of events leading to the incident
An elderly patient was admitted to a major tertiary hospital for management of respiratory failure and urosepsis. The patient’s medical history included ulcerative colitis which was being managed with prednisone and azathioprine. The patient was also taking a considerate number of other medications.
On specialist advice, allopurinol 300mg daily was commenced for treatment of the urosepsis. This medication was provided to the patient throughout the duration of her inpatient stay and was dispensed to the patient for continuation post-discharge. The patient was not advised to discontinue any of the medications that they were taking prior to administration. The patient continued to take the newly prescribed allopurinol and her existing azathioprine treatment.
Approximately five weeks later the patient was readmitted with pancytopenia, anaemia, and a non-ST-elevation myocardial infarction. It was deemed that this presentation was highly likely to be the manifestation of azathioprine toxicity caused by a significant drug interaction between azathioprine and allopurinol.
The patient deteriorated over the course of her admission and subsequently died. The team conducting the root cause analysis found that the drug interaction between azathioprine and allopurinol was a significant contributing factor in the patient’s death.
Major contributing factors
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The prescribing doctor was not aware of the well documented interaction between azathioprine and allopurinol, and did not check the patient’s existing medication regimen for interactions with allopurinol prior to prescribing.
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Prescribers within the hospital felt that pharmacists would review their prescribing, checking for drug interaction etc. This may have decreased the amount of care taken by the prescribing doctor.
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It is not clearly evident that a complete and thorough review of the patient’s pharmaceutical treatment was conducted during her first admission.
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When the patient’s discharge medications were prepared, a pharmacist was not notified of the drug interaction alert generated by the pharmacy dispensing software.
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The pharmacist performing the final check on the patient’s discharge medications did not identify the interaction between allopurinol and azathioprine.
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The pharmacy dispensing software used throughout NSW utilises the Stockley drug interaction database which lists the interaction between allopurinol and azathioprine as being in the second most serious interaction category, A2. In this pharmacy, dispensing technicians only need to notify pharmacists of A1 interaction notifications, the most serious category.
The Health Service has taken some remedial action to prevent similar incidents happening in the future.
Health care practitioners should take the following points from this case to reflect on their practice:
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Prescribers need to be aware of the risks associated with drug interactions, particularly those that are well recognised and have the potential to cause significant harm to patients.
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Doctors should take appropriate care when prescribing to ensure that they have considered possible drug interactions.
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Pharmacy departments should check their internal processes to ensure that drug interaction alerts are adequately assessed.
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A timely and thorough review of pharmaceutical treatment should occur for all patients, on every admission.
Link to ADRAC (Australian Adverse Drug Reactions Bulletin, Volume 19, Number 1, February 2000) – http://www.tga.gov.au/adr/aadrb/aadr0002.htm
References
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DT Kennedy, MS Hayney, KD Lake. Azathioprine and allopurinol: the price of an avoidable drug interaction. The Annals of Pharmacotherapy: Vol. 30, No 9, pp. 951-954.
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ADRAC. Allopurinol and azathioprine. Fatal interaction. Med J Aust 1980; 2: 130.
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ADRAC. A reminder – the allopurinol azathioprine interaction. Aust Adv Drug React Bull, February, 1985.
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Boys IW. Allopurinol-azathioprine interaction. J Intern Med 1991; 229: 386.
Australian Curriculum Framework for Junior Doctors (ACF)
The national working group behind the ACF project has recently published a range of new resources on its website (http://www.cpmec.org.au/Page/acfjd-project). For example:
- National Guidelines for ACF Resource Development: to help develop educational resources to address Capabilities within the ACF.
- National Term Description Template: IMET has its own term description template, but the national template is similar, and the ACF site also includes guidelines on writing term descriptions that might be helpful to Term Supervisors and examples of term descriptions that incorporate the ACF for terms in general medicine, general surgery, emergency medicine and haematology/oncology.
- National Guidelines for Implementation of the ACF, with advice and handouts for specific audiences of JMOs, Medical Educators, Supervisors and Administrators.
These are just some of the resources available, so the web site is worth a visit by anyone working to develop prevocational training.
Medical student and AMC graduates allocation
IMET is currently allocating AMC graduates to training positions starting in June 2009. For 2010 training positions, the allocation process will commence in late April 2009. As directed by the NSW Department of Health, Australian citizens and permanent residents who are Commonwealth-supported graduates of NSW universities will be guaranteed an allocation (this is in line with the Council of Australian Governments agreement). All other graduates, including interstate and AMC graduates, will be allocated to remaining positions based on need in line with the priority list.
IMET is currently working on a a merit selection system to allocate graduates for 2011.
New team structure at IMET
IMET has restructured its System and Support Operations Division (which carries out the functions of accrediting prevocational training facilities and allocating trainees) to improve customer service. The new teams have dedicated staff who are responsible for a group of prevocational training networks.
Click here to view the relevant contacts for your prevocational training networks.
Guidance for new training terms in pathology
From 2012 there will be a dramatic increase in the number of Australian medical graduates requiring prevocational training positions. The need to develop innovative approaches to employing and training these junior medical officers (JMOs) provides an opportunity to design rotations that will enable JMOs to gain valuable learning experiences in pathology to enhance their clinical knowledge and skills and possibly stimulate an interest in a pathology career.
The Royal College of Pathologists of Australasia is keen to promote such rotations and provide guidance to pathology departments, hospitals and postgraduate medical councils that may be in a position to implement them.
The templates draw their key capabilities, common problems and conditions, skills and procedures directly from the Australian Curriculum Framework for Junior Doctors. Details of this framework may be viewed and downloaded from the Confederation of Postgraduate Medical Councils website at http://curriculum.cpmec.org.au/
Activities have been selected as far as possible to map to this framework. The templates are not prescriptive, but are designed to be selected from and modified according to local needs and to provide assistance with completing applications in accordance with local regulations and requirements.
After consultation with a number of pathologists, four possible models have been developed.
Click here to download the templates and supporting information.
http://www.bloodsafelearning.org.au/— your free on-line guide to clinical transfusion practice
The Blood Watch program run by the Clinical Excellence Commission in NSW Health has endorsed BloodSafeLearning as a tool to learn the fundamentals of red cell transfusion, storage and appropriate use. Doctors and nurses can register, undertake learning and complete on-line assessment at http://www.bloodsafelearning.org.au/. On successful completion of the course, participants receive a certificate, and the program can be used by hospitals to help meet accreditation requirements around transfusion practice. DPETs can use the Learning Management Tool to check that all their JMOs have successfully completed the program.
Topics covered in this course include:
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Basic facts about blood transfusion and blood donation
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The risks and benefits of red cell transfusion, and the factors that should be considered when making the decision to transfuse a patient
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How to correctly collect and label a pre-transfusion blood specimen
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Picking up blood from a transfusion service provider or blood fridge
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Administering a transfusion
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Monitoring the transfused patient (including an overview of transfusion reactions).
Greater Southern and Sydney South West Area Health Services have made BloodSafeLearning a mandatory learning exercise for nurses and JMOs, and other Area Health Services are rolling it out in various ways. Click here to download a spreadsheet with a list of contact people and the current status of the program in your Area.
The BloodWatch program in New South Wales is able to set up key people in each cluster/network/hospital or Area so that they can access the User Reports from the Learning Management Tool. DPETs can use the Learning Management Tool to check that all their JMOs have successfully completed the program. If you are interested in being set up as an administrator, contact Carolyn Der Vartanian, Program Leader - Blood Watch, Clinical Excellence Commission (carolyn.dervartanian@cec.health.nsw.gov.au; tel 02 9382 7818).
BloodSafeLearning: What you need to know:
- The e-learning program requires Adobe Flash Player. You cannot use it without this free software.
- Each user must have an email address. This can be either a work address or a personal address. Each user will receive only 2 emails from this program: a welcome letter and the completion certificate.
- There are five modules. One is designed for porters/couriers who transport blood. The other four are intended for all medical and nursing staff.
- There is an assessment component for each module. Upon successful completion a User will receive a certificate via email.
- The Program will take between one and two hours to complete. Once you have registered you can go back to it at any time to finish the course.
- To start the course, go to http://www.bloodsafelearning.org.au/.
Useful resources from The New England Journal of Medicine
The NEJM provides many excellent clinical training videos (plus pdf summaries) on its website, which is available to subscribers and via CIAP.
Among the 23 topics currently available are: blood-pressure measurement, basic splinting techniques, peripheral intravenous cannulation, cricothyroidotomy, and orotracheal Intubation.
See: NEJM videos http://content.nejm.org/misc/videos.shtml?ssource=recentVideos or access via CIAP, http://www.ciap.health.nsw.gov.au/
DPET funding: clinical training grants for prevocational trainees
The NSW Department of Health policy in relation to clinical training grants for prevocational trainees is set out in Policy Directive PD2005_259 (http://www.health.nsw.gov.au/policies/PD/2005/PD2005_259.html).
The Policy was issued on 8 October 2002 and predates the creation of IMET, so in several respects it requires interpretation. For the benefit of Directors of Prevocational Education and Training, the Prevocational Training Council would like to clarify the following terminology in the Policy:
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“Medical Education Training & Workforce Unit” = “Workforce Development and Leadership Branch”
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“Directors of Clinical Training” = “Directors of Prevocational Education and Training (DPETs)”
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“Postgraduate Medical Council of NSW” = “NSW Institute of Medical Education and Training”
In addition, the Prevocational Training Council would like to draw the attention of DPETs to the following provisions of the policy:
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The policy makes it clear that the clinical training grant is a subsidy only and it is expected that hospitals with Postgraduate Year 1 and 2 doctors will contribute funding (direct and in kind) to support Directors of Prevocational Education and Training in the education of and advocacy for junior doctors at their hospital.
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Clinical training grants are to be used to promote education and supervision of prevocational trainees. The policy makes it clear that this purpose is not to be interpreted narrowly. Acceptable uses of the funding include but are not limited to conducting educational activities, establishing or improving educational resources and activities, establishing or improving educational resources for clinical teachers and providing secretarial support to DPETs for their educational work. The Prevocational Training Council considers that reasonable proposals along the following lines should be considered acceptable uses of the funding:
a. Hosting a social event specifically intended to promote interaction between trainees and term supervisors
b. Funding trainees or term supervisors to attend an educational event such as a conference or workshop
c. Improving the amenity of educational facilities within the hospital.
In general, inspiring approaches to promoting the supervision, education and training of prevocational trainees are encouraged and are a suitable use of the clinical training grant.
- The policy is quite clear on the subject of where funds will be held and how they will be disbursed (see points 8 to 15 in the Policy Directive). NSW Health pays out all IMET money to AHSs in one allocation, called the Medical Specialty Training Networks Funding Allocation (DOHRS no. MB345). The DPET funding is included within this allocation. Each hospital should have a cost centre called 'DPET funding' or 'DCT funding' or similar. It is the responsibility of the DPET to know their cost centre name and number. They can then check that funds are paid into that cost centre. Unexpended funds from one year should be rolled over into the next financial year (see points 14 and 15). A letter will be going to DPETs from IMET next financial year telling them what has been allocated to them and who to contact in their AHS if there are problems.
DPET reports
A new template for the DPET prevocational training report for the period 1 July 2008 to 30 December 2008 will be sent out this week. The new template has been simplified and wherever possible IMET has filled in items on the report on your behalf to save you time. Please complete the report by Monday 4 May and email or post it back to the Prevocational Program Coordinator, Craig Bingham.
Subscribe/Unsubscribe
- This newsletter is sent to Directors of Prevocational Education and Training by NSW IMET as part of our effort to support DPETs. To change your subscription address, add a new subscriber, or unsubscribe from the newsletter, please contact Craig Bingham (cbingham@imet.health.nsw.gov.au).
- A similar newsletter is sent to prevocational trainees. If your prevocational trainees are not receiving the JMO newsletter, ask them to email Craig Bingham (cbingham@imet.health.nsw.gov.au) with their contact details so that they can be added to the mailing list.
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