Intermountain-led CMS Hospital Engagement Network
Adverse Drug Event PreventionSeptember 23, 2014
Affinity Call
Jason Trahan, Pharm.D.Director of Pharmacy – Medication Safety,
Baylor Scott & White
Lucy Savitz, Ph.D., M.B.A.HEN Director
Outline for Discussion
• Review of the HEN ADE work • “Just-one-thing” Recommendations• High performers• Pharmacy Patient Safety at Baylor Scott &
White • Q & A/ Discussion
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
Pharmacy Patient Safety
September 23, 2014
Jason Trahan, Pharm.D.
Director of Pharmacy – Medication Safety
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Presentation Outline
• Focus on Pharmacist involvement in two of ten patient safety areas:
– Adverse Drug Events– Use of Data
» Vancomycin– Response to current literature
» Fentanyl Patches» Haloperidol Intravenous Use
– Injuries from Falls• Response to current literature
– Zolpidem
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Adverse Drug Events
• Changes evaluation from facility specific to enterprise-wide in 2013.
– Increased usefulness of data and trending
• Reported Quarterly at enterprise and facility meetings.
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Vancomycin
• Facility specific practices collected / analyzed.• Pharmacy and Therapeutics Committee
approval to standardize infusion times to 10 mg/min.
• Implementation in Electronic Health Record, IV Pump Library, Order Sets, etc.
• Fully implemented first quarter 2014.
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Proactive Use of Data
• Facility specific practices collected / analyzed.• Pharmacy and Therapeutics Committee
approval to standardize infusion times to 10 mg/min.
• Implementation in Electronic Health Record, IV Pump Library, Order Sets, etc.
• Fully implemented first quarter 2014.
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Response to Current LiteratureFentanyl Patch Disposal
• FDA Alerts:– April 2012 (Accidental Exposure)– September 2013 (Patch Writing Color Change)
• Institute for Safe Medication Practices:– August 2013 (“Bystander Apathy – We ALL have a
role in prevention”)
• Action Plan– Outpatient– Inpatient
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Action PlanFentanyl Patch Disposal
• Outpatient Baylor Health Enterprises Pharmacies– Pharmacists Utilizing standardized teaching tool
emphasizing disposal• Tool can be found: www.ismp.org/AHRQ/default.asp
• Inpatient Care– Nursing Education for Fentanyl, Fold, and Flush– Consistent message across continuum of care
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http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/UCM337803.pdf
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Haloperidol Use
• Society of Critical Care Medicine– Revised Guidelines Published January 2013– Prior to update, the use of haloperidol for the
treatment of delirium was in the guidelines (Level C Recommendation)
– “There is no published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients”
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Haloperidol Use
• Action Items:– Removed from Enterprise ICU Delirium Order
Sets.– Recommended that patients receiving via the
intravenous route of administration considered for telemetry monitoring.
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Zolpidem
• Journal of Hospital Medicine 2013;8:1-6 “Zolpidem is Independently Associated with Increased Risk of Inpatient Falls” – Published January 2013.
• FDA Drug Safety Communication – January 2013
– FDA Requires lower recommended doses…
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Zolpidem
• Action Plan:– Electronic Health Record Changes
• Revise order sets to remove pre-selection of prn insomnia medication.
• Dose revision to remove 10 mg ordering option– Only 5 mg on order sets– Removal of 10 mg order sentence for quick ordering
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AHRQ eLearning Lesson on Preventing ADE “Preventing ADE: Individualizing Glycemic Targets Using Health Literacy”
An interactive eLearning course offered by the Office of Disease Prevention and Health Promotion, teaches providers how to:
• Apply health literacy strategies to provide personalized care for patients with diabetes, and to help them understand and act on information to prevent hypoglycemia
• Apply current, evidence-based guidelines for individualizing glycemic target goals
• Adopt the teach back method and shared decision-making in the health care setting
Continuing education (CME, CNE, CEU and CPE) is available
Visit http://health.gov/hai/training.asp#preventing_ades to participate
