Reasonable adjustments to application of the Medication Safety Standard for adult patients living with intellectual disability in Australian hospital settings

Adults living with intellectual disability experience higher rates of preventable adverse medication events across the medicine pathway compared to their peers without disability.


PURPOSE OF REVIEW
The eight National Safety and Quality Health Service Standards (NSQHSs) developed by the Australian Commission on Safety and Quality in Health Care ([ACSQHC], the Commission), aim to protect the public from harm, to improve the quality of health service provision, and provide a mechanism for quality assurance of healthcare delivery within hospital settings. 1Each standard mandates a set of criteria, items, and actions to be undertaken by health systems, managers, or clinicians.The particular intention of the fourth standard, the Medication Safety Standard, is to ensure that clinicians are competent to safely prescribe, dispense, administer, and monitor use of appropriate medications and that consumers using hospital services are informed about their medications, understanding their individual medication needs and risks, 1(p36) Principles to improve the quality and safety of medicine usage are recognised as a priority by quality and safety systems as medication incidents make up the second highest reported category of adverse hospital event, after falls, within Australian contemporary hospital incident monitoring systems. 2 In application of the NSQHSs, the Commission appreciates that different populations within Australia experience variations in the safety and quality of hospital-level health care, including those involving medicines. 3,4][7][8][9][10][11] To this end, the Commission recognises a requirement for the development of practical refinements to the application of all of its mainstream standards, called 'reasonable adjustments', to optimise the quality and safety of healthcare delivery for people living with intellectual disability. 12,13ithin health settings, reasonable adjustments have been interpreted to mean refinements to usual clinical processes and organisation intended to reduce barriers and improve access to, and participation of, people living with disabilities in healthcare. 14They are aimed at optimising the ability of individuals living with intellectual disability to access and participate in mainstream health services and at the same level of quality as their peers living without disability. 15,16Importantly, reasonable adjustments to the standards are intended to be shaped by the nature of the disabilities of individuals and their views, 17 by their systems of family and disability supports, 13,18,19 and by an operational interface between health and disability at a sectoral level. 16Such reasonable adjustments would also be intended to complement the Commission's resources across the standards as they relate to people with cognitive impairment, currently mainly limited to dementia and delirium. 20ith this in mind, the primary aim of this review is to propose reasonable adjustments to the application of the Medication Safety Standard for the hospital inpatient population of adults living with intellectual disability.It formulates these by three sequential steps: (1) provide overview of the operational aspects of the mainstream Medicine Safety Standard, especially those actions more directly involving patients; (2) review data and range of influences on the quality and safety of medicine use by adults with intellectual disability, then taking into account these steps; (3) formulate reasonable adjustments to the usual knowledge, process, content, and organisation that underpin the generic application of the standard, with each reasonable adjustment aligned with a particular action of the standard.Presented in this way, this paper constitutes both a reference source and an operational guide to the application of the Medication Safety Standard as suited for adults living with intellectual disability.The inclusive format facilitates access by pharmacists, as well as their clinical colleagues, quality and safety managers in hospital and disability settings, disability supports, and sectoral professionals.
Underpinning all sections of the paper is a premise that improving the safety and quality of medicine use by adult inpatients living with intellectual disability involves a partnership with people with lived experience of intellectual disability, coupled with an active interface at the health and disability sectoral and individual professional levels.Consistent with this perspective, the author, with skills and extensive experience spanning clinical, research, educational aspects in the health care of adults living with intellectual disability within mainstream hospital settings, quality and safety in healthcare and disability care delivery, operational aspects of the disabilityhealth interface, interdisciplinary collaboration, and a lived experience of intellectual disability (by way of family and friends), feels uniquely qualified to offer the proposed reasonable adjustments as practice points.These points are open to further scrutiny and development by people living with intellectual disability, disability and health workers and sectors.The author intends that reasonable adjustments will complement the work of the Commission and be of interest to a broad range of Australian and non-Australian health and disability workers, people with living intellectual disability and their families, and health and disability sector administrators.

SOURCES OF INFORMATION The Medication Safety Standard
The standard comprises four criteria with 12 items and 15 actions relating to: (1) clinical governance and quality improvement for medication management; (2) documentation of patient medication profiles; (3) continuity of medications across handovers and; (4) medication management processes (Table 1).The standard's actions span all steps of the medicine pathway: prescribing, dispensing, administration, adherence and monitoring of medicines, medication safety review and their governance, as well as safe practices for procuring, supplying, storing, compounding, and manufacturing medicines.Hospital organisations and management will have policies, protocols, verification systems, nominated quality and safety monitoring staff, and clinical staff will have specific roles and responsibilities to operationalise these obligations.
Adherence to the actions listed in Table 1 has implications for usual clinical content (e.g.best possible medication history including allergies, patient clinical needs), processes (e.g.medication reconciliation, medication management plan, creating and distributing medicine list, medication review, involving patients), knowledge (e.g.medication evidence for best practice, safe and secure medicine storage, decision support tools, patient health literacy, adverse medication risk factors), and organisation (e.g.clinical governance to monitor effectiveness and performance, to manage and monitor risk, to ensure continuing improvement, medication chart formats, medicine management formats, medication advisory committee) to be developed, maintained, and updated with respect to patients' medication care.The Commission provides a range of helpful resources to support all of these domains of this standard for the general population. 21,22he Commission acknowledges that while medicine quality and safety are important for every patient, in a climate of limited resources and drives for efficiency, not every hospital inpatient will be offered, or even need, the full gamut of actions described in the standard.A risk screening tool is instead used to identify patients at high risk of medication-related harm and target them for particular scrutiny.The methodology to develop these tools is generally left to organisational policy and/or clinical expertise. 23The Commission has highlighted the critical importance of identifying patients with cognitive impairment within their health organisation risk screening tools, and particularly offering them the full range of Actions 4.5 and 4.6 Medication reconciliation, 4.10b Medication review, 4.11 Information for patients, and 4.12 Provision of a medicine list. 20

Medicine Pathway Experiences
As reported in a recent review by the Pharmaceutical Society of Australia (PSA), 11 adults living with intellectual disability experience medicine safety problems at any stage of the medicine pathway, possibly at multiple stages.These occur in association with failures of usual quality and safety medicine practices across the entire medicine management pathways and are very likely under-reported and under-recognised (Table 2).
At the prescribing level, under-prescribing, overprescribing, and inappropriate prescribing practices were noted to be very common.p25-30) At the same time, mainstream guidelines for pharmaceutical treatments for chronic illnesses were under-prescribed.Failures to evaluate appropriateness of medicine and to detect medication interactions, contraindications, 'when required' maximum doses, duration of medicine use, and consent to use, a particular medicine were common.The disproportionately high number of people living with intellectual disability living with multiple physical health co-morbidities often requiring polypharmacy (≥5 medicines) as a valid prescribing circumstance was noted but still posing a risk for medicine incidents.
Errors in dispensing of medications were also common, with causes identified including an inability to get to the pharmacy due to associated physical disability or to get to the prescribing doctor for a repeat prescription.p31-35)  Quality and safety of medicine administration and adherence were often found to be compromised due to dosing instructions unable to be read or understood, packaging that could not be opened, and taste or formulations of medicines which the person could not tolerate.There appeared to be insufficient awareness that when medicines are crushed to ease oral swallowing due to dysphagia or for use in percutaneous enterogastrostomy devices, their efficacy may be reduced due to change in drug activity, residues left in the mouth, or food in the stomach.p37-43) The quality and safety of processes for monitoring of medicine side effects, recognition of adverse drug reactions and maintaining therapeutic levels of medicines were also recognised as inadequate.For example, a difficulty in enduring venesection for testing of drug levels may have meant that either the first-line recommended medication was not prescribed or toxicity was not monitored.
Additionally, themes of evidence about the quality and safety of medicine use suggest that mainstream strategies which work to ameliorate rates of medicine errors may not work as effectively for or not be offered to people living with intellectual disability.For example, measures such as patients identifying their own medicine errors, 24 self-management and telephone follow-ups with patients, 35 and having access to material 36 may not work effectively or be harder to implement for people living with intellectual disability in isolation; 8 practices such as Home Medicines Reviews undertaken by community pharmacists for the purpose of reviewing medicine quality were found to be used minimally for people living with intellectual disability, 11(p22) and when they were undertaken, their effectiveness amongst this group was mixed. 37e Impact of Intellectual Disability Although intellectual disability is not a cognitive impairment due to a medical illness in the way dementia and Administration and adherence 11(p37-43) Texture, type, mode of delivery, flavours, inability to distinguish between types of medicines, using inhalers, swallowing, inability to read medicine names and instructions, dysphagia, crushing tablets, timing with meals Difficulty in opening packages, using inhalers Disability support availability and accreditation for correct timing Disability support workers regulatory aspects (e.g.S8 medications) Safe storage of discharge medications at home Medication charts for home from hospital, short-duration medications, PRN medications Error management systems in hospital and at home Monitoring 11(p44-45) Opportunity for inpatient review of medications, options for home medicines review recommendation Recognition and reporting of side effects of medication Difficulty in measuring levels of medications Recognised general population risks for adverse medication event also experienced by people living with intellectual disability Transition between primary and secondary care, moves within wards, at clinical handover, interruptions, informal bedside conversations, misread or unread orders 24,25 Medication history by proxy 26 Language and cultural barriers 27 Lower health literacy 28,29 Polypharmacy and multimorbidity 31 Influence of disability supports health literacy 32,33 Negative social determinants of health 34 PRN = pro re nata; S8 = schedule 8. delirium are, it is a condition defined by lifelong limitations in cognitive and adaptive functioning skills affecting expressive and receptive communication, reasoning, learning of new skills, problem solving, and planning. 38s evidenced by the earlier data, these limitations fundamentally, though very variably, impact the required levels of health literacy to independently manage steps involved in the mainstream medicine pathway.This means that in mainstream health settings, many adults living with intellectual disability will be unable to: independently self-manage their medicines; understand medicines' use; report medication lists, allergies, and adverse side effects; read and understand product information; present for testing of medicine levels; describe symptoms of adverse medicine events or medication toxicity; purchase medicines; understand complex medicine information; organise repeat prescription scripts; source a pharmacist; numerically work out dosing and timing; learn new skills for medication devices; consent to medicine use; and follow a dosing schedule.These limitations, in turn, impact the ability to accurately apply Actions 4.5 and 4.6 Medication reconciliation, 4.10b Medication review, 4.5 and 4.6 Medication reconciliation, 4.11 Information for patients, and 4.12 Provision of a medicine list.
][41] Limitations in expressive and receptive communication also mean that concerns, symptoms experienced, or responses from people living with intellectual disability may be displayed by them as functional behaviours and vocalisations.These are frequently misinterpreted as 'behavioural problems', or a manifestation of mental illness, or intellectual disability, so-called diagnostic overshadowing. 42p25-30) Behaviours, as expressions of communication of fears or anxiety or illness, are also common in unfamiliar hospital settings and other health settings. 34Such behaviours complicate the processes of ensuring medicine quality and safety for them, especially in recognising side effects or detecting responses to therapy.
Intellectual disability is not infrequently associated with various neurodevelopmental, motor, and sensory conditions. 38Such factors may impact ingestion and efficacy of medicines due to impaired swallowing, high waste from spillages, intolerance of medication textures, 43 and inability to open medicine preparations, predisposing to the observed rates of reduced medication efficacy.
Intellectual disability is associated with multiple medical problems per person, 44,45 lower rates of healthy living, 46 and more frequent transitions involving hospitalisation, living situations, disability supports, and health practitioners compared to persons living without disability, 11(p22), 53,47 all known risk factors predisposing to preventable adverse medicine risks.
The influence of the endurance of multiple negative social determinants of health, 33 degrees of discrimination and chronic devaluation in mainstream society, 48 a poorly trained medical workforce in terms of intellectual disability, 49 and an inadequate health sector response to the lowered health literacy associated with intellectual disability all work against optimal quality of medication care amongst people living with intellectual disability.Disability supports report the health system as being unprepared to work with people living with intellectual disability; 6 clinicians reportedly have low levels of communication skills required to engage with people living with intellectual disability and pharmacists may not use appropriate communication techniques for people with low health literacy. 26At the systems level, low levels of health resources allocated to addressing the priority needs of inpatients with intellectual disability and insufficient understanding of intellectual disability are reported even though causes and reports of adverse medicine events have been well established for years. 50p139-40) Because of such biases, patients living with intellectual disability often simply do not receive the same level of applied quality and safety of medication care as their peers living without disability.Reported evidence suggests usual mainstream monitoring policies and processes are not applied or not suitably fashioned for the needs of inpatients living with intellectual disability, 52 and the trends of continuous quality improvement of medicine quality and safety observed amongst the general population are not observed among this group. 34he issues of cognitive and adaptive behavioural limitations, medical comorbidity polypharmacy, dosing concerns, multiple prescribers and high rates of transitions of care, lower levels of vigilance, population-related negative social determinants of health, lower health literacy, inadequate patient-clinician rapport, and unsupportive health systems are all individual risk factors for medicine error and, when bunched together and experienced by people living with intellectual disability, create the perfect environmental storm for medicine-related errors amongst adults living with intellectual disabilities. 25,53All such described biopsychosocial implications of living with intellectual disability for medicine safety and quality need to be considered in the formulation of reasonable adjustments.

Disability Supports and Sector
Disability supports have variable but significant responsibility for, and influence on, the quality and safety of medicine management for the people living with intellectual disability they support in community and hospital settings. 5,26,54Ineffective, inadequate, or excluded disability supports for people living with intellectual disability when they need to access and participate in mainstream health services, including medication issues, have been found to directly contribute to avoidable premature mortality and morbidity. 11,34isability supports may derive from family, friends and, in Australia, formal disability support workers (either employed by disability service providers or working independently) funded by the National Disability Insurance Scheme (NDIS).Disability support workers are not required to have any formal educational qualifications, a factor tied to the lower levels of health literacy noted among paid disability supports.31,32 In contrast to disability supports from families and friends, funded workers are also subject to multiple regulations, legislation, and obligations for quality and safety of medicine-related management.These may derive from their state or territory, the Commonwealth of Australia via the NDIS Act 2013 (Cwth) the NDIS Quality and Safeguards Commission, principles of interface between health and NDIS, or individual service policies (see examples listed in Appendix 1), but not those of the NSQHCS Medication Safety Standard.They address such issues as class of medications legally able to be administered by support workers (e.g.Schedule 8 [S8]), reporting obligations related to certain medicines (e.g. chemical restraint), credentialling processes for disability supports to administer medications, specifications for medication chart formats, guidance for PRN (pro re nata) prescriptions, prescriptions, medication error procedures, responsibilities for non-orally delivered medications, and accountability, storage, and security of medication at home.19 This multiplicity of regulations, while criticised for being overly complex and lacking in transparency and accountability, 55 presumably is aimed at addressing the low levels of health literacy among disability support workers and protecting the rights of individuals living with intellectual disability.
In hospital settings, individuals living with intellectual disability variably require their disability supports to facilitate their access to, and participation in, quality and safe comprehensive health care (inclusive of medication).These supports are additionally needed to help individuals understand their own health needs and make informed health decisions, to have a good understanding of their usual health and potential symptoms to watch out for, including when there are changed behaviours or function, to ensure the provision of accessible health information, and to facilitate informed decision making regarding health care using the appropriate communication methods, involving family, independent support persons or guardians in the decision-making process, where appropriate. 20Specifically, in relation to disability supports for medications, for example in application of Actions 4.5, 4.6, 4.1b, 4.11, 4.12 (Table 1), patients living with intellectual disability would require their disability supports to assist in provision of accurate reporting about current medicines, doses, and allergies, swallowing and dysphagia, tolerance of oral textures, medication administration techniques, method of ingestion, spillages, and tolerance.In addition, supports need to help patients understand side effects and indications, be able to make judgements about PRN on discharge, interpret changes in demeanour as a possible adverse drug reaction, and assist in compliance with dosing schedules and administration of medications on discharge and medication storage at home.Additionally, inference from studies of diagnostic overshadowing suggests that when disability supports are able to provide a fuller life picture of their clients, demonstrate communication with their client, and provide reliable histories, the risks of medication mishap associated with hospitalisation may be minimised. 56rom a practical perspective, for disability supports to play these roles in hospital settings, they need to have a good understanding of the person for whom persons for whom they are providing support and the scope of their role in the hospital setting.In addition, they need to be able to explain to health professionals their sectoral medication management regulations and to be present with the person they support during transitions to and from hospital, and generally during the day of the hospitalisation period.Clinicians too need to adequately engage with supports and acknowledge their importance.Medication issues arise throughout the admission process, and not just on admission or discharge.Unresolved operational aspects around securing appropriate selection and the presence and roles of disability supports for medication safety relate to funding (e.g.NDIS or hospital funding of required disability support workers in hospital), demarcation of roles (e.g.disability support workers would generally not administer medicines in hospital), and problems with consistency (e.g.known high turnover of disability workforce 57 ).The circumstances of simultaneously active, but non-overlapping, disability and health sectoral quality and safety medication standards, mutual ignorance, and the absence of any health-disability interface problem solving forum come into play and must be factored into any reasonable adjustments around medication quality and safety for adult patients living with intellectual disability.

KEY FINDINGS Reasonable Adjustments to the Medication Safety Standard for Inpatients Living with Intellectual Disability
Perusal of the literature reveals a raft of usable, general, reasonable adjustments to mainstream health care for people living with intellectual disability, all aimed at reducing barriers within healthcare settings and providing the best possible care. 58Like the approach used in this paper, they have been developed by reviewing the healthcare experiences of people living with intellectual disability in healthcare settings, taking into account both the impact of living with cognitive impairment due to intellectual disability and the structures and systems of disability supports.This paper offers two additional unique considerations in the formulation of reasonable adjustments: each refinement is specifically aligned with a particular action of the Medication Safety Standard, and each refinement is classified as being relevant to usual clinical knowledge, process, content, or organisation involved in application of that action.This proposed system for developing reasonable adjustments is considered to make their implementation more appealing by being focused, specific, simple, and rationally linked to a mainstream action. 59Their impact is intended to be supplemented by other measures to support the implementation of reasonable adjustments, for example, those addressing stigma. 60able 3 lists these proposed reasonable adjustments, categorised by relevance to usual clinical processes, content, knowledge, and organisation and paired with their particular relevance to a mainstream Medication Safety Standard action.

Reasonable Adjustments to Usual Clinical Processes
The first reasonable adjustment to usual clinical processes is the addition of 'intellectual disability' as a specific category in the usual risk screening tool for medicine management.Even when the risk screening tool contains a category of 'cognitive impairment', intellectual disability should be identified as a distinct subcategory given the different phenotypes of cognitive impairment, sectors, and supports and their influence on medicine management as described above.Patients living with intellectual disability will then be provided with the full raft of medicine management planning encompassing Actions 4.10b Medication review, 4.05 and 4.06 Medication reconciliation, 4.11 Information for patients, and 4.12 Provision of a medicine list.
Reasonable adjustments to clinical processes should include removal of barriers to accessing information about medicines (Actions 4.11, 4,12).This means adopting a flexibility to cater for sensory disabilities and the low levels of health literacy of people living with intellectual disability and their disability supports.Processes need to adjust current materials to formats of Auslan, Braille, audio, easy-to-read materials about medications which are suited to the range of disabilities associated with intellectual disability and health literacy levels of patients living with intellectual disability and their disability supports.
Adjustments to clinical processes include a closer than usual liaison between the pharmacist and the patient's clinician to monitor in particular, medicine indications given the reported very high rates of under-, over-, and inappropriate prescribing.Prior prescription of antipsychotic, anticholinergic, and sedative medications should be an immediate trigger to assess their indication (Actions 4.10a, b).
Reasonable adjustments to usual processes will require direction to specifically engage closely with patients and their disability supports to obtain and document accurate medication information (Actions 4.05, 4.06, 4.07, 4.09, 4. 10, 4.11, 4.12).
Clinicians should take care to avoid the process of diagnostic overshadowing.This is an important consideration in monitoring the safety of new medicines, as part of Criterion 4, Medication management processes.Such reasonable adjustments focusing on communication processes enable evaluation of levels of health literacy of patients and their disability supports, a fundamental factor in medication safety across the medication pathway.
Reasonable adjustments to usual clinical processes relating to discharge should involve the scrutiny of discharge medications in the light of the disability medications.Such considerations include confirming the credentialling status of disability support workers to deliver medications at the prescribed time and formulation, the legality of disability supports to administer prescribed medications (for example, S8), and the formatting of discharge medication lists (Actions 4.11, 4.12).Information about discharge medications should be presented in ways that are understood by patients living with intellectual disability as much as possible and their disability supports.A devised checklist system of discharge requirements for medication safety, a set which is compatible with disability support training (e.g.right medication, right time), may reduce the risk of medication errors in transition across sectors and primary and secondary care.
Incorporating reasonable adjustments to usual processes to partner with consumers is a critical component of Action 4.03.Consumer engagement within health organisations should ensure that existing consumer groups adequately represent the views of people with the lived experience of intellectual disability (and including those with disability industry experience) and that specific resources which will assist in meeting medicine information needs of inpatients living with intellectual disability and their disability supports are available (e.g.Council for Intellectual Disability).Such processes will enable pathways to formalise processes to ensure that medication discharge planning is embedded in standard healthcare delivery with an appropriate person-centred approach and is inherently compatible with regulations within the disability sector, NDIS quality indicators, and codes of conduct.As well, such adjustments to usual governance should cater for the enhancement of intersectoral engagement and will certainly predispose to a helpful cross fertilisation across the health and disability sectors and the means by which to solve operational interface problems, including those of quality and safety, and demarcation disputes (Actions 4.01, 4.02).
As a reasonable adjustment to usual processes, medication advisory committees, which play a clinical governance role, could take a proactive stance on auditing medicine management among inpatients living with intellectual disability as part of the hospital's commitment to continuous quality improvement.Such medication advisory groups should develop processes, for example, to ensure that adverse drug reactions experienced by inpatients living with intellectual disability are noted as such, acted upon, and not simply dismissed as a manifestation of the disability (Action 4.01).
Usual processes of compliance with the Medication Safety Standard would normally include a discharge letter to the patient's GP.For patients living with intellectual disability an additional process is a discharge medication summary for them to take home, for their disability supports, and their person responsible (Action 4.12).

Reasonable Adjustments to Usual Clinical Content
Reasonable adjustments to usual clinical content relate to a requirement of admitting clinicians to include and document biopsychosocial content about their patients' intellectual disability, syndrome, other disabilities, usual disability support structure, substitute decision maker, mobility, and communication, as well as details of the method of home medicine management.Such information is fundamental to the application of all direct-patient actions (Actions 4.03, 4.05, 4.06, 4.07, 4. 10, 4.11).Clinical content should now additionally include a review of the patient's medicine storage at home, packaging and any particular administration nuances (for example, only with certain foods), a check that disability support staff working at the time medication is due are credentialled for medication administration, or that elderly parent carers can understand and use the packs (Actions 4.10, 4.11, 4.12).
Content within existing pharmacist templates on medicine management should also be adjusted to contain information on aspects of swallow, nutrition, usual administration of medication and risks: administration, swallow, interactions, polypharmacy, crushed, peg, liquid or tablet, spillage, usual behaviour for now and use for next time medical summary in the admission history content (Actions 4.05, 4.06).
Reasonable adjustments to content relevant for discharge medication lists should contain template checklists of compliance with the disability sectoral regulations on medications (Actions 4.01, 4.02, 4.03, 4.04).

Reasonable Adjustments to Usual Clinical Knowledge
A general knowledge of the biopsychosocial implications of living with intellectual disability, the significance of disability supports and sectors, and awareness of attitudinal, practical, the NDIS and its safety and quality standards and indicators, and process barriers experienced by people living with intellectual disability should be appreciated as relevant for all criteria, items, and actions of the Medication Safety Standard.Clinicians should work to improve their disability literacy, reflect on their attitudes to people living with disability and, in the context of this topic, also seek to gain specific knowledge of the medication-related high risks and factors underpinning those risks relevant for this population.Amongst the acknowledged main blocks to the application of any reasonable adjustments are clinician ignorance and poor attitudinal stance in relation to people living with intellectual disability. 60cross all criteria of the Medication Safety Standard, additional knowledge by hospital workers about the medicine-related regulations within the disability sector, 60,61 NDIS Commission quality indictors and practice standards, 19 NDIS worker codes of conduct, 62 and the tenets of the United Nations Convention on the Rights of Persons with Disability 15 is required as a reasonable adjustment so that disability sectoral regulations and legislation applicable to safety and quality in medication are able to be adhered to on discharge.Differing regulations impact the ability of support workers to validly administer any medications, and even accredited disability support workers have legislated limitations on what medications they can administer to their clients living with intellectual disability (Action 4.12).All this impacts the ability of health services to generate a medicine list and assist in decision support tools for medicines (Action 4.13).General knowledge of the NDIS Commission approach to the prescription of medications which may be deemed chemical restraint, as well as the interface with mental health services, should be known (all criteria).
The Home Medicines Review program undertaken by community pharmacists is a potentially useful resource for discharged patients living with intellectual disability, with such resources adding an extra layer of postdischarge safety and quality for a vulnerable patient group (Criterion 3).

Reasonable Adjustments to Usual Clinical Organisation
One of the most helpful recommended reasonable adjustments to usual clinical organisation in health care is the allocation of more time. 58This applies also when attending to quality and safety of medicine management for inpatients living with intellectual disability.0][41] Disability support workers have high turnover, 57 and depending on their roster they may not know patients well, and discussions may have to be repeated within a single inpatient admission.Inpatient bedside appointments may have to be made for discharge planning and medication management to ensure safe continuity of medication care from hospital to home, since disability supports may not be with the patient all of the time during their stay (Criteria 2 and 3).
Reasonable adjustments to the usual organisation involved in meeting each of the four actions within Criterion 1 on clinical governance involve considerations of intellectual disability and disability supports.For example, Action 4.01 on implementing policies and procedures for medication management for adult patients living with intellectual disability should additionally consider and respect organisational aspects within the disability sector (including the NDIS) and their quality improvement monitoring systems.This presents an opportunity for shared learning and bi-sectoral improvements.Reasonable adjustments to the organisation involved in Action 4.01 on identifying training requirements for medication management should now involve collaboration with individuals living with intellectual disability, their disability supports, and sector to improve disability literacy in relation to their experiences along the medication pathway, amongst health professionals, and sectors.

Implications for Resources, Actioning, Intersectoral Engagement
Initiating and implementing the reasonable adjustments will likely take some extra resourcing.However, it is suggested that once the processes are in place, the systemic efficiencies gained will outweigh the initial sense of burden.The proposed reasonable adjustments are deemed to be reasonable since they do not entail very high costs or severe disruption, and they are fundamentally based around currently mandated standards.
Negative attitudes of health professionals towards intellectual disability have been deemed a barrier to the application of broad sets of reasonable adjustments in hospital settings. 60It is hoped that the strategies of focusing on reasonable adjustments to the Medication Safety Standard and using smaller and simpler categories of adjustments related to usual content, knowledge, process, and organisation will appeal to clinicians to enable them to apply the adjustments as part of practice, regardless of personal attitude.Furthermore, motivation to apply reasonable adjustments may be enhanced by their perceived validation by the Commission via a recent release on intellectual disability and the standards. 63The reasonable adjustments proposed in this paper are completely consistent with the Commission's fact sheet for clinicians outlining four steps they can take to make reasonable adjustments: 63 plan for reasonable adjustments, understand individuals and their disabilities, communicate directly with the person, and act on a person's health needs.
In any case, individual clinical and management leadership may still be required to kickstart the processes of implementation of reasonable adjustments, to lead in prioritising the health care of adults living with intellectual disability, to direct use of existing resources for this purpose and to advocate for improvements in the education and training of medical students and specialists.At a systems level, health organisations need to reach out to and collaborate with people living with intellectual disability, their families, funded disability supports, and disability disability and NDIS sectoral parties to continue to refine, inform, and cross-fertilise values and sectoral processes and help problem solve in the application of reasonable adjustments to mainstream health services.The current formulation of reasonable adjustments to the Medication Safety Standard stands as a work of progress in this regard.

CONCLUSION
In response to an observed relatively high rate of suboptimal safety and quality in medicine management experienced by inpatients living with intellectual disability, this paper has had an ambitious scope: to outline the framework of the Medication Safety Standard highlighting those elements deemed by the Commission as crucial for people with cognitive impairment, to summarise themes of suboptimal safety and quality medicine-related issues experienced by people living with intellectual disability, and to speculate on the significance of living with intellectual disability with formal and informal disability supports on such experiences with medicines.Then, based on this background, the aim was to formulate a series of reasonable adjustments categorised by those relevant to usual clinical processes, content, knowledge, and organisation involved in meeting the Medication Safety Standard for people living with intellectual disability in hospital settings.
As a result, actions of the Medication Safety Standard for adult patients living with intellectual disability are now paired with specific operational reasonable adjustments for their implementation.They are relevant for hospital administrators and clinicians with leadership roles by pharmacists.As part of continuous quality improvement, with future refinements to proposed reasonable adjustments, collaboration with consumer representatives with lived experience of, and industry experience in, intellectual disability is recommended in parallel with the collection of quantitative and qualitative data of outcomes to ensure a 'living document'.

Table 1
National Safety and Quality Health Service Standard 4. Medication Safety Standard criteria, items, and actions 1 Item Action Criteria 1. Clinical governance and quality improvement to support medication management.Organisation-wide systems are used to support and promote safety for procuring, supplying, storing, compounding, manufacturing, prescribing, dispensing, administering, and monitoring the effects of medicines.

Table 1
(continued)Item Action Provision of a medicines list 4.12 The health organisation has processes to: a. Generate a current medicines list and reasons for any changes b.Distribute the current medicines list to receiving clinicians at transitions of care c.Provide patients on discharge with a current medicines list and the reasons for any changes Criteria 4. Medication management processes Health service organisations procure medicines for safety.Clinicians are supported to supply, store, compound, manufacture, prescribe, dispense, administer, monitor, and safely dispose of medicines.
a. Safe and secure storage and distribution of medicines b.Storage of temperature-sensitive medicines and cold chain management c.Disposal of unused, unwanted, or expired medicines High risk medicines 4.15 The health service organisation: a. Identifies high-risk medicines used within the organisation b.Has a system to store, prescribe, dispense, and administer high-risk medicines safely

Table 2
Pharmaceutical Society of Australia 11 summary of adverse medicine pathway experiences by people living with disability

Table 3
List of proposed reasonable adjustments to the application of the Medication Safety Standard for adult inpatients with intellectual disability