Transcript Increasing pharmacists reporting of adverse medication

Increasing Pharmacists reporting
of adverse medication incidents
Being Ready for new risks and Opportunities
Prepared by Tim Garrett
Northern Sydney Central Coast AHS
Aim

To improve the Health Services ability to respond to adverse medication
safety incidents by increasing the number of pharmacist-generated
incidents entered into the Incident Information Management System (IIMS)
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Nature and extent of the problem

190,000 medication-related admissions per annum [2-3% all Australian
admissions (2002-2008)], at a cost of $660 million per annum 1

Medication errors remain the second most commonly reported incident into
the NSW Incident Information Management System (IIMS) 2

Under-reporting of adverse
medication incidents (50-96%) limits
our ability to identify and respond to
new risks and opportunities for safety
improvement 3
Organisational
Lack of anonymous
reporting
Availability of incident
forms
Complexity of
reporting tools
Individual
More
Controllable /
Modifiable
Belief that near misses don’t
need to be reported
Not knowing who should report
Not believing in usefullness of
reporting
Lack of Time
Unknown what, where, to whom
or how to report
Fear of reprisal
Organisational
Climate and
Tradition
Severity of the Error
Culture of Blame
Lack of Interest /
motivation
Less
Controllable /
Modifiable
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Uribe, C. et al. 2002
1. Roughead, R et al. Medication Safety in Acute Care. Part 1 (2002-2008). Aus and NZ Health Policy 2009
2. NSW Department of Health and the Clinical Excellence Commission (CEC) 2009. Incident Management
in the NSW Public Health System 2008: January to June. Published May 2009.
3. Cullen D, et al. The incident reporting system does not detect adverse drug events: A problem in quality
2
assurance. Joint Commission Journal on Quality Improvement 1995; 21: 541548.
Strategic importance

Medication related misadventure is commonplace, highly avoidable, and
accounts for significant patient morbidity and wasted resources

Drug therapy is a complex and evolving part of therapeutics presenting
ongoing known and unknown challenges

Healthcare systems need to be alert to new and evolving risks such as those
posed by medication-related injury

Safety alert systems to help manage this risk but rely on frontline clinical
staff to notify of incidents of actual or potential harm

Poor ‘compliance’ with these systems; hampers our ability to develop
strategies for existing risk and limits our ability to anticipate, or respond to
new challenges
3
Aim

To improve the Health Services ability to respond to adverse medication
safety incidents by increasing the number of pharmacist-generated
incidents entered into the Incident Information Management System (IIMS)
Why Pharmacists?

Pharmacists' interventions to improve patient outcomes are widely accepted
by the profession as a cornerstone of clinical practice, 4 and are effective at
improving patient and organisational outcomes. 5,6

Given the scale of the problem and limited resources available the working
party elected to focus on one professional group
4. Society of Hospital Pharmacists of Australia committee of Specialty Practice in
Clinical Pharmacy. J Pharm Pract Res 2005; 35: 122-146
5. Dooley MJ, et al. British Journal of Clinical Pharmacology 2003; 57: 513-521.
6. National Institute for Health and Clinical Excellence Review Body for Interventional
Procedures (ReBIP). Systematic review: 2007
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Planning & implementing solutions
Barriers to using the IIMS notification system (Pharmacists n=62)
160
100
140
80
Frequency
120
100
60
80
40
60
40
20
20
Barriers
‘Time pressures’ and
Literature
expert
opinion,
‘Difficulty review,
with using
IIMS’
were
workshops
with
targettouser
groups,
significant
barriers
incident
drafting and
version testing
reporting
0
m
Ti
w
e/
D
Frequency
Percent
Cum %
0.7
i
or
cu
ffi
k
lo
lt y
ad
w
p
re
ith
F
51
34.0
34.0
Proportion
or
ee
ti n
db
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o
to
k
ac
l
/M
ak
25
16.7
50.7
in
g
r
f fe
di
ce
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n
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o
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e
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U
21
14.0
64.7
rt
u
ns
re
w
8
5.3
70.0
ha
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C
om
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4.7
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th
er
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18.0
100.0
1
1
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1
0.4
0.3
Anonymous Questionnaire:
Identify barriers to
‘drug incident reporting’
0
rt
Barriers to Intervention Reporting (Pharmacists n=62)
0.6
0.5
Percent
Project steering committee and
working party established
0.2
UCL=0.4709
_
P=0.3323
LCL=0.1938
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Planning & implementing solutions
Time and IT concerns ‘key barriers’ to
incident reporting
Planning, workshops with target user
groups, drafting and version testing
Range of strategies to address these
‘key barriers’
Preferred option being development
of a streamlined tool
CCH tool to facilitate reporting
into IIMS
6
Outcomes & evaluation
Pharmacists reported interventions into IIMS
Baseline



Increase in IIMS medication incidents
from 9.8 to 97 per month
Pharmacists as a reporting group
increased from 3.8% to 42%
Incidents reported into IIMS
150
Intervention
1
UCL=134.4
125
100
_
X=86.5
75
50
LCL=38.7
25
0
Pharmacists represent 1.4% of combined
nursing, medical, pharmacy workforce
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul
Month (Jan 2008 - Jul 2009)
Pharmacists reported interventions CCH v IIMS
700

CCH reporting tool implemented Sept 08,
(mean 296 reports/month)
Review panel (for CCH tool data into
IIMS), feedback and reporting
C CH Tool Reports
IIMS Reports
600
Intervention Reports

500
400
300
200
100
0
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
Month (Sept 2008-July 2009)
May
Jun
Jul
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Sustaining change

Increased pharmacist generated incidents into the CCH reporting tool and
IIMS have been sustained for > 12 months

Positive feedback from pharmacists users, concept meets its planned
objectives (formal evaluation planned)

Maintained regular relevant feedback (self-generated or via manager)

User confidence in data (accuracy, consistency and completeness assured
via ‘peer review group ‘of all interventions)

User confidence via safety initiates and activities resulting from data which
is being reported
8
Lessons learned

Identified key barriers to pharmacists reporting of adverse medication
incidents (time and limitations with IIMS)

This project provides a cost neutral approach to improving the volume of
reporting

This approach has enhanced our understanding of medication errors

Provides an opportunity to plan strategies to mitigate / eliminate future
harm

Drug-related harm is a major cause of morbidity and mortality in
hospitalised patients and is relevant to all health settings.
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Future scope

Further evaluation is planned at 12 months to validate the perception of an
improved 'intervention reporting culture' and to quantify the utility of the
reporting tool

Future planned enhancement to reporting tool (web-based)

Roll out to other facilities with NSCCAHS
Acknowledgements

Peter Hill

Diane Reeves

David Gilbert

Pharmacy Team (Gosford/Wyong Hospitals)
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