Transcript October 4th presentation NJCTH,,NEED Title for anticoagulation

Reducing Harm from
Anticoagulants
Mike Serra, PharmD, BCPS
Clinical Pharmacist Specialist
Clinical Pharmacy Coordinator
Morristown Memorial Hospital
Reduce Harm…
What do we really mean by
“harm?”
IHI’s Definition of Medical Harm
According to the IHI Medical Harm is;
 Unintended physical injury resulting from or
contributed to by medical care (including the
absence of indicated medical treatment), that
requires additional monitoring, treatment or
hospitalization, or that results in death.
Such injury is considered harm whether or not it
is considered preventable, whether or not it
resulted from a medical error, and whether or
not it occurred within a hospital.
Donald M. Berwick, MD, MPP
Institute for Healthcare Improvement
for Healthcare Improvement
Just how much medical harm occurs
in the USA annually ?
 There are 40 to 50 incidents of medical harm to
patients for every 100 admissions
 Harm results in approximately 37 million hospital
admissions annually
 Approximately 15 million incidents of medical harm
occur in US hospitals annually
Agency for Healthcare Research and Quality; 2001
Adverse Drug Events (ADEs)
 Adverse drug events are very common contributors to
medical harm
 Some 770,000 people are injured annually as a result of drug therapy
in hospitals each year.1
 Incidence for Adverse drug events
 Varies between 2 to 7 ADEs per 100 admissions among hospitals
that have conducted ADE studies.1
 ADEs are costly
 USA hospitals spend > $ 5 million dollars annually due to adverse
drug events
1Agency
for Healthcare Research and Quality; 2001
How often is anticoagulation
associated with adverse drug events?
 On average, patients receiving long-term
anticoagulation therapy are in the therapeutic range
55% of the time1
 The other 45% of the time they are either
 Sub therapeutic- diminished effect
 Supra therapeutic- risk for toxicity
 In a study by Bates et al., anticoagulants accounted for
4% of preventable ADEs and 10% of potential ADEs2
1.) Walraven C, Oake N, Wells PS, Forster AJ. Burden of potentially avoidable anticoagulant-associated
hemorrhagic and thromboembolic events in the elderly. Chest 2007;131(5):1508-15.
2.) Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events:
Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29-34.
Injury Associated with Excessive
Anticoagulation
Methods
 Atlantic Health is a two-hospital health system totaling
approximately 1000 beds and accounting for 57,000
admissions and 116,000 ER visits annually
 Strong history of structured accountability
 Using quality measures in a balanced scorecard
 Focused on linking administrative and medical efforts to improve the
quality of care we offer
Atlantic Health Methodology
 Atlantic Health considered any harm associated with
medication use to be an opportunity for improvement
 {Since patient harm occurs across the spectrum of ADEs, adverse
drug reactions, and medication errors}.
 Included all ADE whether or not they are associated
with harm
 This perspective expanded the scope of improvement
 Traditional efforts to prevent medication errors
 Developed new strategies to detect and mitigate harm as soon as it
could be detected.
Atlantic Health Methodology
 Computerized identification of abnormal lab levels
 Inpatients with aPTT > 130, INR > 5
 Focused review of 30 random charts performed monthly
 Identification of severity of harm
Attempt to identify reasons for abnormal lab value
associated with anticoagulation
 Use this information to drive medication safety
interventions
Interventions:
Anticoagulants - Heparin
 ISMP Antithrombotic Self-assessment
 Anticoagulation flow sheets
 Weight-based heparin protocol
 With and without GP2b3a inhibitors/lytics
 Caution kg and lb weight documentation!
 Developing inpatient and outpatient dosing services
 HIT guidelines
 Minimize available concentrations
 All dispensing from pharmacy
 Guidelines for holding therapy and reversal
Interventions:
Anticoagulation – Warfarin
 Build standardized protocols into CPOM
 Vitamin K administration
 Warfarin guidelines
 Standardize and minimize strengths utilized
 Plot INR results & dosage changes on run chart
 Partner with Patients
 Medication reconciliation list
 Medication/diet changes
 Compliance and monitoring requirements
Quality Improvement Plan
 Created a warning in pharmacy computer system
 Hard stop preventing dispensing of warfarin
 System alerts pharmacist if INR ≥ 4
 Prompts pharmacist to address elevated INR with physician
 Pursuing ASHP antithrombotic certificate traineeships
 CMO and CEO support establishment of an antithrombotic service to
foster a safer environment
 Engaging GME and residency program directors
 Establish resident and attending physician safety champions
 Creating synergy between medication reconciliation and adverse
event reduction teams to improve medication safety
Leadership roles
 Process Improvement Teams
 Multidisciplinary
 Physician leadership
 Pharmacy driven
 Evidence-based
 Rapid cycle improvement model
 Small tests of change
Behavior change models
 Target senior leaders, team leaders, and front-line staff
 Engage, Educate, Execute, Evaluate
 Identify evidence-based interventions
 Select interventions with the most impact on outcomes and convert
them to behaviors
 Develop measures to evaluate reliability
 Measure baseline performance, and
 Ensure patients receive the evidence-based interventions.
 It’s about changing culture
Pronovost et al. Creating high reliability in health care organizations. HSR 41(4). Part II 15991617.
Strategies for Leading Change
 Recruiting for a Corporate Medication Safety
Coordinator
 Regular communication and assistance provided to all sites
 Monthly teleconferences including all sites to discuss issues,
interventions, and cases
 Process sharing
 Standardized process and manual
 Established Campus Medication Safety Pharmacist
 Recruiting campus physician and quality leads
 Established Presence on the Balanced Scorecard
 Visibility and accountability
Morristown Memorial Hospital:
ADEs per 100 Therapies
Anticoagulation YTD ADE Rates
Year-To-Date Through July 2007 ANTICOAGULATION ADE
TRIGGER RATE - MMH
50
40
30
20
10
0
Jan Feb Mar Apr May Jun
Jul Aug Sep Oct Nov Dec
2007 14.5 17.8 18.0 16.8 16.4 16.3 16.8
2006 25.3 25.4 24.1 23.9 21.3 19.5 18.1 17.3 16.9
16.1 16.0 16.3
Overlook Hospital:
Anticoagulation YTD ADE Rates
ADEs per 100 Therapies
Year-To-Date Through July 2007
ANTICOAGULATION ADE TRIGGER RATE - OH
50
40
30
20
10
0
Jan
Feb
Mar
Apr
May
Jun
Jul
2007
29.0
27.0
24.4
22.2
23.2
21.9
22.0
2006
36.8
42.2
36.3
34.2
33.7
33.4
32.9
Aug
Sep
Oct
Nov
Dec
31.9
33.1
32.0
31.9
31.8
How will we measure our success?
 Continue to measure and trend ADE rates
 Measure impact of our interventions
 Once we meet our goals
 Medication Safety is a ongoing process
 Move onto the next high alert agent
 Consistency is the key to success
Thank You!