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

Armadale Health Service(AHS)

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

Prevent Future ADEs:

• Goal: ADEs to harm:

KPI1

KPI2

– ↑ KPI3

KPI4

Lesson learnt:

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)

Conclusion:

• To ADEs:• Timely Med Rec within ENCD• Involve all clinicians in MR