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The Prevocational Training Council of IMET is working with the JMO Forum, the prevocational training networks, the GCTC and DPETs at each hospital to support and develop your "on the job" education and supervision. We hope to keep you updated with current items of interest via this newsletter.
— 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!
Error on end of term form
Many of you will have wondered why the first page of the end of term assessment form asks for the “Mid-term appraisal date”. This is an error — it should ask for the “End-term assessment date”. IMET apologises for this error, which will be corrected next time we print the form, but please be aware that the old form with the error may still be around at the end of Term 2.
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.
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.
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/.
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.
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.
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/
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- This newsletter is sent to Junior Medical Officers by NSW IMET as part of our effort to support your education and training. To change your subscription address, add a new subscriber, or unsubscribe from the newsletter, please contact Craig Bingham (cbingham@imet.health.nsw.gov.au).
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