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Intermountain-led CMS Hospital Engagement Network Adverse Drug Event Prevention June 24, 2014 Affinity Call. Outline for Discussion. Review of the HEN ADE work “Just-one-thing” Recommendations High performers National ADE action plan. Overall Progress Through Q1 2014. - PowerPoint PPT Presentation
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Intermountain-led CMS Hospital Engagement Network
Adverse Drug Event PreventionJune 24, 2014
Affinity Call
Outline for Discussion
• Review of the HEN ADE work • “Just-one-thing” Recommendations• High performers• National ADE action plan
Overall Progress Through Q1 2014
Intermountain HEN 2012-Q1 2014 ADE w/ Harm
Intermountain HEN 2012-Q1 2014 ADE w/ Harm
Intermountain HEN 2012-Q1 2014 ADE per 1000 Patient-Days
Intermountain HEN 2012-Q1 2014 ADE per 1000 Patient-Days
Intermountain HEN 2012-Q1 2014 PSI 12 Post Operative PE or DVT
Intermountain HEN 2012-Q1 2014 PSI 12 Post Operative PE or DVT
Intermountain HEN 2012-Q1 2014
• ADE Due to Opioids
• Controlled Postoperative Serum Glucose
• Excessive Anticoagulation with Warfarin
– Low Reporting
Just One Thing MatrixRecommendations
Getting Started Working Harder Ahead of the Curve
Identify accountable teams to review all ADEs and work on performance improvement.(moderate level of evidence)
Build in automated medication administration alerts and processes, i.e., bar coding.(low level of evidence)
Automate ADE triggers and implement into pharmacy work flow with patient specific alerts.
High Performing Hospital Highlight…ADE w/ Harm
Most Improvement
SANPETE VALLEY HOSPITAL - CAHSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ
DENVER HEALTH MEDICAL CENTER
SOCORRO GENERAL HOSPITAL
BEAR RIVER VALLEY HOSPITAL
EDEN MEDICAL CENTER
RIVERTON HOSPITAL
DIXIE REGIONAL MEDICAL CENTER
VALLEY VIEW MEDICAL CENTER
SUTTER ROSEVILLE MEDICAL CENTER
Lowest Rates
MILLS PENINSULA HEALTH SERVICESSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ
LOS BANOS MEMORIAL HOSPITAL
PARK CITY MEDICAL CENTER
MENLO PARK SURGICAL HOSPITAL
LINCOLN COUNTY MEDICAL CENTER
SEVIER VALLEY MEDICAL CENTER
HEBER VALLEY MEDICAL CENTER
GARFIELD MEMORIAL HOSPITAL
UPPER CONNECTICUT VALLEY HOSPITAL
High Performing Hospital Highlight…
Most Improvement
SANPETE VALLEY HOSPITAL - CAH
MENLO PARK SURGICAL HOSPITAL
DENVER HEALTH MEDICAL CENTER
SEVIER VALLEY MEDICAL CENTERSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ
SUTTER SOLANO MEDICAL CENTER
BEAR RIVER VALLEY HOSPITAL
SUTTER COAST HOSPITAL
NOVATO COMMUNITY HOSPITAL
ALTA BATES SUMMIT MEDICAL CENTER
ADE per 1000 Patient-Days
Lowest Rates
MENLO PARK SURGICAL HOSPITAL
GARFIELD MEMORIAL HOSPITAL
SANPETE VALLEY HOSPITAL - CAH
DENVER HEALTH MEDICAL CENTER
MILLS PENINSULA HEALTH SERVICES
ALTA BATES SUMMIT MEDICAL CENTER
SEVIER VALLEY MEDICAL CENTER
LOS BANOS MEMORIAL HOSPITALSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ
UTAH VALLEY REGIONAL MEDICAL CENTER
High Performing Hospital Highlight…
Most Improvement
SUTTER LAKESIDE HOSPITAL
SUTTER SOLANO MEDICAL CENTER
SUTTER AUBURN FAITH HOSPITAL
VALLEY VIEW MEDICAL CENTER
LDS HOSPITAL
MCKAY DEE HOSPITAL CENTER
PROVIDENCE ST VINCENT MEDICAL CENTER
UTAH VALLEY REGIONAL MEDICAL CENTER
SUTTER MEDICAL CENTER OF SACRAMENTO
DENVER HEALTH MEDICAL CENTER
PSI 12 Post Operative PE or DVT
Lowest Rates
LOGAN REGIONAL HOSPITAL
SUTTER AUBURN FAITH HOSPITAL
SUTTER SOLANO MEDICAL CENTER
PARK CITY MEDICAL CENTER
SUTTER DAVIS HOSPITAL
HILLCREST BAPTIST MEDICAL CENTER
RIVERTON HOSPITAL
VALLEY VIEW MEDICAL CENTER
ESPANOLA HOSPITAL
SUTTER TRACY COMMUNITY HOSPITAL
2014 plans for improvement
• Webinar • Collect and share best practices across our network
hospitals & system in a single document
