The Health Roundtable

Using IHI Global Trigger Tool to monitor Adverse Drug Events

Presenter: Helen WardThe Prince Charles Hospital _ Qld

Innovation Poster SessionHRT1215 – Innovation AwardsSydney 11th and 12th Oct 2012

14-4d_HRT1215-Session_WARD_TPCH_QLD

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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

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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

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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. 4

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KEY CHANGES IMPLEMENTED 10 randomly selected medical records reviewed

fortnightly

Primary reviewers (4 nurses, 1 pharmacist, 1 HIM) 2 reviewers independently use “triggers”, coding,

incident reports Meet together to agree on AE (Harm)

Primary reviewers meet with medical reviewer (physician, EDMS)

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

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   Frequency for Period:

Cycle 1 to 48 (April 2010 to March 2012)

   

Adverse Events

Severity

Harm Category (16% Present On

Admission ) 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

Total 100 63 29 0 7 1

           

           

           

           

           

TPCH Adverse Event and Severity by Harm Category (480 cases)

Severity levels: E: Temporary harm requiring intervention

F Temporary harm requiring initial/prolonged hospitalisation

G: Permanent harm

H: Intervention required to sustain life

I: Death6

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Data base

Oct 10Apr 11

Adverse Events / 1000 beddays (Cycles 1 - 48)

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.01 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

Cycle - Cycle Start Date

AE

/100

0 be

dday

s

AE / 1000 beddays

Apr 10

Oct 10

Apr 11

Oct 11

31.940.1

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Comparison with other IHI GTT sites

AE /1000 pt days

% ADE

TPCH (24 mo)

36.4(16% POA)

25(28% POA)

N Carolina 56.5 28

New Zealand 46.9 50

POA : present on admission8

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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

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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

E - thrombophlebitis due to fluclox 10

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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

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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

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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!

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