Quality ColloquiumAugust 22, 2005

REDUCTION OF ADVERSE DRUG EVENTS

Kathy Haig

Director Quality Resource Management

Risk Manager/Patient Safety Officer

OBJECTIVES

Introduce process changes that contribute to reduction of adverse drug events

Discuss the impact of culture on medication event reduction efforts

Review tools used in process improvement collaborative

Learn about Medication Reconciliation

OSF ST. JOSEPH MEDICAL CENTER

Located in Bloomington, IllinoisServes a community of 100,500 peopleLicensed for 157 bedsProvides Open Heart Surgery Services

Started “Beating Heart” Program in 19995 Hospital-Owned Physician Office PracticesUrgent Care CenterLicensed as a Level II Trauma Center

GOALS

Maintain a cultural survey score above 4

Involve patients with safety

Conduct 3 phases of med reconciliation

Decrease the Dispensing and Ordering FMEA

Promote Dosing Service for Anticoagulants

Deploy Pharmacy Based Order Sets

Comply with JCAHO Patient Safety Goals

Safety tool kit (RCA, FMEA, Human Factors, CAS, TRM)

ADE’S / 1000 DOSES

OSF St. Joseph Medical Center

Events/1000 Days

0255075

100125150175200225250

Date

Eve

nts

/100

0 d

ays

SJMC

Idealized Design of the Medication System

Key Areas of FocusCultureReconciliationDispensing OrderingHigh Risk Medications

Cultural Transformation

Improve Safety Climate or culture Cultural survey or safety climate score

Focus on harm, not errors Meaningful, avoids blame game

Focus on process and systemPoor processes; not “bad people”

Focus on communication and teamwork

High Reliability

Medication System

Safer Core ProcessesSafer Core Processes• RCA

•FMEA •Simulation •CRM • CAS•Human factors

Leadership Driven Culture of SafetyLeadership Driven Culture of Safety

Collaboration. System thinking Focused on Change Evidence

Patient Involvement

High Reliability Characteristics

Preoccupation with failureIs 80% good enough?

Deference to expertiseMost knowledgeable takes charge

regardless of role

Ask yourself:What have I missed today?What should I have seen that I didn’t?

STARTING THE JOURNEY

CULTURESystem Thinking

Influenced by patient condition, tasks, staff, environment, teamwork, management

Collaboration Friendly competition; accomplish more, faster

Commitment to Change New, better ways; test ideas

Evidence Based Order Sets; Protocols

CULTURESTAFF INVOLVEMENT

Non-Punitive Reporting Policy

Systems Thinking Focus on harm and processes; not the care provider

Safety Briefings with Employee Feedback

Unit CouncilsStaff identify and address unit safety concernsInvolves staff in development of processes

CULTUREPHYSICIAN ENGAGEMENT

Patient Safety is a standing agenda item

Safety Briefings and Feedback is provided

Monthly updates of PI projects are provided

Root Causes Analyses include physician input

Human Factors included in the Peer Review

Expectations and goals of the organization are shared

Efforts made to obtain input while being mindful of the physician’s time

PHYSICIAN INPUT

Ad Hoc team developed process and protocol for Peri-operative Beta Blockade

Anesthesiologists developed Epidural Protocol

Pediatricians requested child Med Safety Brochure for their offices

Internists and CV Surgeons assisted in development of IV Insulin Infusion Protocol

CULTUREPATIENT INVOLVEMENT

Satisfaction survey questions for safety

Medication Safety Brochure given to all new admissions; distributed by physician offices

Community resource collaboration to encourage patient to keep updated med list

Patient education channel is available 24/7 with information about disease

Community Board serves a dual role as the Patient Advisory Council

PATIENT SAFETY POSTERALSO AVAILABLE IN SPANISH

Be Involved in Your CareMake sure the nurse checks your armband before giving you your

medicine.

Ask the nurse about medication that is unfamiliar to you BEFORE you take it.

Make sure the staff and physician washes their hands before / after providing care to you

MEDICATION RECONCILIATION

DefinitionA process of identifying the most accurate list of all medications a patient is taking and using this list to provide care in any setting

It requires comparing the patient’s list of current medications against the physician’s admission, transfer and discharge orders.

WHY DO THIS?Provides the ability to accurately compare home meds to meds ordered during hospitalizationDetects medication errors before they happenPromotes continuity of care between different levels of careWrong dose, route or frequency may be prescribedImportant meds may be omitted

RECONCILIATION PROCESSMed history is completedMed history is compared with admission medication ordersTransfer reconciliation is conducted when the patient moves to a different level of careDischarge reconciliation compares the meds ordered during hospitalization with those ordered to be taken at homeVariances between med history and admission orders is clarified with the physicianWhat is included?Current home meds, OTC, Herbals Includes dose, route, frequency, time of last dose

WHERE TO GET INFORMATION

Patient or family

Patient’s pharmacy

Previous medical records

Primary care physician’s office

Patient’s medication bottles

BARRIERSBureaucracyComplexity of communication--interruptionsAccountability—staff too busyLack of teamwork—office does not have updated list or nursing home list is confusingPatient brings in incorrect listPatient does not take what is marked on the bottlePatient does not know names of medsPatient is unable to tell you

ADMISSION RECONCILIATION

OSF Healthcare System Performance Goals : SJMC : Pursuing Perfection In Safety : National Patient Safety-Admission Medication

Reconcilliation : By Month

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

[Oct-04 to Present : Inhouse Data Collection]

Percentage Rate

Goal Admission Reconciliation 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Admission Reconciliation N 19 18 16 18 17 17 16 19

Admission Reconciliation D 20 20 20 20 20 20 20 20

Rate Admission Reconciliation 95% 90% 80% 90% 85% 85% 80% 95% 0% 0% 0% 0%

Oct-04

Nov-04

Dec-04

J an-05Feb-05

Mar-05

Apr-05

May-05

J un-05 J ul-05Aug-05

Sep-05

TRANSFER RECONCILIATIONOSF Healthcare System Performance Goals : SJMC : Pursuing

Perfection In Safety : National Patient Safety-Transfer Medication Reconcilliation : By Month

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

[Oct-04 to Present : Inhouse Data Collection]

Percentage Rate

Goal Transfer Reconciliation 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Transfer Reconciliation N 5 7 7 6 6 8 8 5

Transfer Reconciliation D 10 10 10 10 10 10 10 10

Rate Transfer Reconciliation 50% 70% 70% 60% 60% 80% 80% 50% 0% 0% 0% 0%

Oct-04

Nov-04

Dec-04

J an-05Feb-05

Mar-05

Apr-05

May-05

J un-05 J ul-05Aug-05

Sep-05

DISCHARGE RECONCILIATION

OSF Healthcare System Performance Goals : SJMC : Pursuing Perfection In Safety : National Patient Safety-Discharge Medication

Reconcilliation : By Month

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

[Oct-04 to Present : Inhouse Data Collection]

Percentage Rate

Goal Discharge Reconciliation 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Discharge Reconciliation N 18 19 16 20 18 16 17 20

Discharge Reconciliation D 19 19 18 20 19 18 20 20

Rate Discharge Reconciliation 95% 100% 89% 100% 95% 89% 85% 100% 0% 0% 0% 0%

Oct-04

Nov-04

Dec-04

J an-05Feb-05

Mar-05

Apr-05

May-05

J un-05 J ul-05Aug-05

Sep-05

FMEA—DISPENSING

The Dispensing FMEA has been reduced 66%

Pharmacy reduced/standardized unit stock meds

Pharmacy prepares all non-standard doses

Labels on all IV pumps encourage caution when stopping the pump to make rate or dose changes

IV Drug Administration Reference matrix directs dosages, guidelines, monitoring information

An automated dispensing system was installed

Renovation of nursing and pharmacy workspaces to improve process flow and efficiency

DISPENSING FMEAC Chart : IHI-ADE : Dispensing FMEA Chart

0

200

400

600

800

1000

1200

1400

1600

1800

[Jul-01 To Present : IHI-ADE Data]

Dispensing RPN

UCL=1230

Mean=1129

LCL=1028

Pharmacy O n Unit

Pharmacy Enters O rders

New Info System

FMEA-ORDERINGHazard Vulnerability Score has been reduced 34%A Periop-Beta Blocker Protocol was initiated 1/03Surgical Prophylaxis Antibiotic Protocol developedPharmacists assigned to a nursing unit/enter ordersRenal dosing review based on creatinine clearanceAbbreviationsUnapproved abbreviations are on orders sheets

IllegibilityPharmacists call with any question of the order

Read-BacksNurses read back 95% of all telephone orders and

sign with “TORB”

ORDERING FMEAC Chart : Ordering FMEA Chart

0

20

40

60

80

100

120

140

160

180

200

[O ct-02 To Present : IHI-ADE Data]

Hazard Vulnerability

Score

UCL=180

Mean=144

LCL=108

Pharmacy O n Units

Pharmacy Enters O rders

HIGH RISK MEDICATIONS

Heparin Nomogram

PCA Protocol with default orders

TPN Protocol

IV Insulin Infusion Protocol

Chemotherapy Order Set

Coumadin dosing service

DVT Protocol

Review of all INR’s above 4 to identify opportunities in dosing regimens

SIMULATION

“Sim Man” purchasedSimulation lab createdSimulation used for Clinical Orientation for RN/LPN/US/CNASimulation used for annual skills validationSimulation used for Root Cause Analysis

ROOT CAUSE ANALYSIS

Human Factor Triage Questions incorporated into RCA—approved and applauded by JCAHO

One RCA resulted in improvements that prevented care issues in a subsequent trauma (ED/difficult intubation boxes)

Success of RCA’s spreading—being used independently by other areas such as OR and EMS Services to evaluate a “near miss”

SBAR

SBAR Acronym-Situation, Background, Assessment and Recommendation

Laminated pocket cards including the acronym have been distributed to all nurses

Posters explaining SBAR have been posted in clinical areas and stickers have been placed on phones

Use of SBAR spreading to all areas for any issue

Medical Staff are encouraged to ask staff to use SBAR

SBAR POCKET CARD

In the interest of Patient Safety and to ensure we are giving

complete, accurate information to the physician, please use the following acronym to direct the

information we provide:

S (the current Situation or problem)B (a little about the patient’s Background) A (your Assessment of the patient)R (your Recommendation of what is needed from the physician)

TEAM RESOURCE MANAGEMENT

Improves team efficiency and effectiveness

Includes multiple conceptsCommunication tools—SBARStaff assertionSituational AwarenessBriefingsDebriefingsRed Flags

Initial and refresher training was provided to staff and physicians

BARRIERSLimited ResourcesLack of organization/leadership support Lack of physician buy-inResistance to changeStarting too bigMoving too quickReluctance to share safety concernsMultiple projectsAdded work instead of replacement

LESSONS LEARNED

Involve the right people

Use rapid cycle tests of change

Simplify processes

Share successes

Don’t recreate the wheel—network with others

Communicate

KEYS TO SUCCESS

Leadership Support

Make it a win-win situation

Reward and recognize staff

Provide ongoing feedback

Always make patient safety the priority!

Never give up; there is no obstacle that cannot be overcome!!!

“Safety is like peeling an onion--the more you look, the more you find and each layer makes you cry”.