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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