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Using Key Performance Indicators (KPIs) from Medication Reconciliation (MR) to Quantify and Prevent Future
Adverse Drug Events (ADEs)
Stephen Lim, TT Chih, E FongPharmacy,
Armadale Health Service
Delivering a Healthy WA
Overview:
• Med Rec (MR) in AHS• Aim and Method to quantify MR• Definition of:
– Adverse Drug Events (ADEs) – Key Performance Indicators (KPIs)
• Achievements of KPIs• Prevention of future ADEs• Lesson learnt
Med Rec (MR) in AHS
• Since 2007• SQuIRe funded project• Marketed as Med Matching (M+M) program• 70-90% M+M for all admitted patients• Sustainable program • Common errors in MR
Common Drug Errors in MR
15.3
1.9
52.5
30.3
0
10
20
30
40
50
60
Wrong drug Med Duplication Med Omission Wrong dose
Exclude ADR documentation
Aims and Method to Quantify MR:
• Aims:– To quantify success or failure in MR– Use KPIs to or prevent ADEs
• Method:– Daily data collection from MR activities– Analyse data monthly using 4 KPIs
Definition of ADEs: (Adverse Drug Events Ξ Actual Drug Errors)
• Potential Drug Errors:– MR < End of Next Calendar Day (ENCD) – near misses (rectified before drug admin)– Not counted as ADEs
• Actual Drug Errors:– MR > ENCD– Counted as ADEs due to:
• Med not admin (Rx omission)• Wrong drug/dose admin (incorrect Rx)
Case study (patient AO, 70y, ♀)ADE Ξ Adverse Drug Events Ξ Actual Drug Errors
NIMC NIMC dose BPMH (Best Possible Med History)
Dose admin?
Aspirin (commission error) 100mg mane Ceased months ago 1 dose (ADE √)
Mirtazapine (commission error)
15mg nocte -ditto- 1 dose (ADE √)
Tamoxifen (commission error)
20mg nocte -ditto- 1 dose (ADE √)
Calcium (omitted Vit D) 1 d Ca plus Vit D 1 dose omitted (ADE √)
Frusemide 40mg m 20mg mane Intentional dose change (ADE X)
Olmesartan (omitted HCT) 40mg mane Olmesartan + HCT 40/12.5mg mane
1 dose omitted (ADE √)
Prochlorperazine 5mg mane
(wrong dose)
5mg tds 2 doses missed (ADE √)
Fosamax plus (commission error)
1 weekly Ceased months ago Not admin (ADE X)
Definition of 4 KPIs:
• KPI1 = ADEs per 1000 doses administered
Number ADEs ÷ Number med doses admin (30 random patients/month) X 1000
• KPI2 = ADEs per 100 med written (Rx)
Number ADEs ÷ total med written X 100
• KPI3 = Pharmacy Interventions per 100 patients
Total pharmacist clinical interventions ÷ total MR patients X100
• KPI4 = ADEs per 100 patients seen >ENCD
Number ADEs ÷ total MR patients X 100
ACHIEVEMENT : KPI1 ADEs per 1000 doses
7
5. 9
7. 1
5. 1
2. 8
4. 3
5. 4
4. 8
3. 7
3
5. 1
0
1
2
3
4
5
6
7
8
May-09 J un-09 J ul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 J an-10 Feb-10 Mar-10
Average 4.7 ADEs per 1000 doses= 1 ADE per 200 doses
Trendline ADEs
ACHIEVEMENT: KPI2 ADEs per 100 med Rx
0
5
10
15
20
25
May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10
Per
cen
tag
e
% med discrepancies
% actual ADEs
17 drug errors for every 100 meds written
4 ADEs for every 100 meds written
13 ADEs prevented due to MR
Trendline ADEs
ACHIEVEMENT: KPI3 Pharmacy Interventions per 100
patients
60
4558
140126 121
87 90
170
240
210
4026
35 38
73 69
40 45
116108 110
0
50
100
150
200
250
300
May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10
Ph
arm
ac
y in
terv
en
tio
ns
pe
r 1
00
ad
mis
sio
ns Total interventions
Med Rec interventions
122 clinical interventionsper 100 patients
64 MR activities per 100 patients
Trendline MR
KPI4: ADEs per 100 admissions(Do Nothing KPI!)
0
20
40
60
80
100
120
140
160
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
83 ADEs per 100 patients(MR > ENCD)
Flat trendline: Error when no MR
Lesson learnt:
KPI1 and KPI2 (≠ 0 ADE):• timely Med Rec (within ENCD)• involve all clinicians in MR
• ↑ KPI3:• 50% clinical pharmacist workload is MR related
• KPI4 remains constant if no MR • 0.8 ADE per patient
Assigning Risk Rating to ADEs
ADEs Risk Ratings
38%
57%
5% 0%
Risk rating 0 Risk rating 1 Risk rating 2 Risk Rating 3
ADEs risk rating: from 0-3
0 = near miss
1 = low (no harm has occurred)
2 = moderate (extra monitoring eg. digoxin level had to be ordered, extra obs (BP/BSL) needed, Dr reviewed patient, no extra treatment required).
3 = severe (required extra treatment, t/f to another hospital/unit, ↑ LOS, readmission)