Transcript Medication Error - Health Roundtable

Innovation Poster Session
HRT1215 – Innovation Awards
Sydney
11th and 12th Oct 2012
Using IHI Global Trigger Tool to
monitor Adverse Drug Events
Presenter: Helen Ward
The Prince Charles Hospital _ Qld
The Health Roundtable
4-4d_HRT1215-Session_WARD_TPCH_QLD
1
KEY PROBLEM

Voluntary reporting identifies only 10 to 20 % of
errors
 over 95% medication errors cause no harm to
patients.

Concern that some classes of adverse events are
not being reported
The Health Roundtable
2
AIM OF THIS INNOVATION

To identify events that cause patient harm in
order to:


quantify the degree and severity of harm
provide objective measure of adverse drug events
(ADE) to monitor effectiveness of current medication
safety systems
The Health Roundtable
3
AUSTRALASIAN VERSION of IHI GTT



Developed in conjunction with IHI and HRT
16 hospitals trained by IHI over 5 months from June 2010
Patient harm defined as:
Unintended physical injury resulting from or contributed to by
medical care that requires additional monitoring, treatment or
hospitalization, or that results in death.
The IHI GTT counts only adverse events which cause harm
to the patient whether or not it is the result of an error.
The Health Roundtable
4
KEY CHANGES IMPLEMENTED

10 randomly selected medical records reviewed
fortnightly

Primary reviewers (4 nurses, 1 pharmacist, 1 HIM)



Primary reviewers meet with medical reviewer
(physician, EDMS)



2 reviewers independently use “triggers”, coding,
incident reports
Meet together to agree on AE (Harm)
Agree on Harm and Category
Seek extra data if unclear
Second monthly meeting of all reviewers to discuss all
AE and agree on inclusions/exclusions
The Health Roundtable
5
TPCH Adverse Event and Severity
by Harm Category (480 cases)
Frequency for Period:
Cycle 1 to 48 (April 2010 to March 2012)
Severity
Adverse
Events
E
F
G
H
I
Medication/IV Fluids (28%)
25
16
7
0
2
0
Patient Care (4%)
25
24
1
0
0
0
Hospital Acquired Infection (7%)
13
6
6
0
1
0
Surgery or Other Procedure (19%)
36
17
14
0
4
1
Other
1
0
1
0
0
0
100
63
29
0
7
1
Harm Category
(16% Present On Admission )
Total
Severity levels: E: Temporary harm requiring intervention
F Temporary harm requiring initial/prolonged hospitalisation
G: Permanent harm
H: Intervention required to sustain life
I: Death
6
Adverse Events / 1000 beddays (Cycles 1 - 48)
AE /1000 beddays
140.0
120.0
100.0
80.0
60.0
40.1
31.9
40.0
20.0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
0.0
Apr 10
Oct
Oct
10 10
Apr 11
Apr 11
Oct 11
Cycle - CycleAE
Start
Date
/ 1000
beddays
Data base
The Health Roundtable
7
Comparison with other IHI GTT sites
AE /1000 pt days
% ADE
36.4
25
(16% POA)
(28% POA)
N Carolina
56.5
28
New Zealand
46.9
50
TPCH (24 mo)
The Health Roundtable
POA : present on admission
8
ADVERSE DRUG EVENTS - Present on Admission

E - Hypotension due to GTN
E - Cough secondary to rimapril
F - epistaxis from OD of Warfarin
F - seizures after rapid withdrawal of meds
F - ADR secondary to Amoxil prescribed by GP
F - postural hypotension secondary to diuretics

H - neutropenic sepsis secondary to chemo





The Health Roundtable
9
ADVERSE DRUG EVENTS – Drug Side Effects













E - hypoglaecemia requiring intervention
E - 2 x hypoglycaemic episodes
E - prolonged post op nausea, did not increase LOS
E - nausea & vomiting post op requiring multiple anti emetics
E - prolonged nausea post op
E - fall due to drowsiness with Capanol
E - hallucinations secondary to oxycontin
E - constipation secondary to opiates
E - oversedation with opiates
E - bleeding secondary to aspirin & clopidogril
E - bradycardia due to Metoprolol
E - deterioration in renal function secondary to hyoptension / NSAID use
F - kidney injury ? Secondary to fluclox
10
ADVERSE DRUG EVENTS – Allergies and Other




E - morphine allergy previously unknown – rash
H - anaphylaxis due to adenosine (not previously known allergy)
F - inadequate K+ replacement with IV frusemide --> cramps.
F - OD in ED of own meds
The Health Roundtable
11
OUTCOMES SO FAR

Validated effectiveness of long standing medication
safety systems

ADE reviewed by Medication Safety Committee

2 years data collection completed



No trends requiring further investigation
Insufficient numbers to monitor an intervention
? useful to monitor the effect of changes in funding
The Health Roundtable
12
LESSONS LEARNED

Decisions on priority by Executive/Board





Time allocation
Data presentation/KPI
Definitions and local “rules” essential
Database – use an existing one
Sustainability


Training additional staff
Funding – don’t start without it!
The Health Roundtable
13