jason trahan, pharm.d . director of pharmacy – medication safety, baylor scott & white
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DESCRIPTIONIntermountain-led CMS Hospital Engagement Network Adverse Drug Event Prevention September 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. - PowerPoint PPT Presentation
HEN Readmission Affinity Call
Intermountain-led CMS Hospital Engagement Network Adverse Drug Event PreventionSeptember 23, 2014 Affinity CallJason Trahan, Pharm.D.Director of Pharmacy Medication Safety, Baylor Scott & White
Lucy Savitz, Ph.D., M.B.A.HEN Director
1Outline for DiscussionReview of the HEN ADE work Just-one-thing RecommendationsHigh performersPharmacy Patient Safety at Baylor Scott & White Q & A/ Discussion2Overall Progress Through Q1 2014
3Intermountain HEN 2012-Q1 2014 ADE w/ Harm
4Intermountain HEN 2012-Q1 2014 ADE w/ Harm
5Intermountain HEN 2012-Q1 2014 ADE per 1000 Patient-Days
6Intermountain HEN 2012-Q1 2014 ADE per 1000 Patient-Days
7Intermountain HEN 2012-Q1 2014 PSI 12 Post Operative PE or DVT
8Intermountain HEN 2012-Q1 2014 PSI 12 Post Operative PE or DVT
9Intermountain HEN 2012-Q1 2014 ADE Due to Opioids
Controlled Postoperative Serum Glucose
Excessive Anticoagulation with Warfarin
Low Reporting10Just One Thing MatrixRecommendationsGetting StartedWorking HarderAhead of the CurveIdentify 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 HighlightADE w/ Harm
Most ImprovementSANPETE VALLEY HOSPITAL - CAHSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZDENVER HEALTH MEDICAL CENTERSOCORRO GENERAL HOSPITALBEAR RIVER VALLEY HOSPITALEDEN MEDICAL CENTERRIVERTON HOSPITALDIXIE REGIONAL MEDICAL CENTERVALLEY VIEW MEDICAL CENTERSUTTER ROSEVILLE MEDICAL CENTERLowest RatesMILLS PENINSULA HEALTH SERVICESSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZLOS BANOS MEMORIAL HOSPITALPARK CITY MEDICAL CENTERMENLO PARK SURGICAL HOSPITALLINCOLN COUNTY MEDICAL CENTERSEVIER VALLEY MEDICAL CENTERHEBER VALLEY MEDICAL CENTERGARFIELD MEMORIAL HOSPITALUPPER CONNECTICUT VALLEY HOSPITALHigh Performing Hospital Highlight
Most ImprovementSANPETE VALLEY HOSPITAL - CAHMENLO PARK SURGICAL HOSPITALDENVER HEALTH MEDICAL CENTERSEVIER VALLEY MEDICAL CENTERSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZSUTTER SOLANO MEDICAL CENTERBEAR RIVER VALLEY HOSPITALSUTTER COAST HOSPITALNOVATO COMMUNITY HOSPITALALTA BATES SUMMIT MEDICAL CENTERADE per 1000 Patient-DaysLowest RatesMENLO PARK SURGICAL HOSPITALGARFIELD MEMORIAL HOSPITALSANPETE VALLEY HOSPITAL - CAHDENVER HEALTH MEDICAL CENTERMILLS PENINSULA HEALTH SERVICESALTA BATES SUMMIT MEDICAL CENTERSEVIER VALLEY MEDICAL CENTERLOS BANOS MEMORIAL HOSPITALSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZUTAH VALLEY REGIONAL MEDICAL CENTERHigh Performing Hospital Highlight
Most ImprovementSUTTER LAKESIDE HOSPITALSUTTER SOLANO MEDICAL CENTERSUTTER AUBURN FAITH HOSPITALVALLEY VIEW MEDICAL CENTERLDS HOSPITALMCKAY DEE HOSPITAL CENTERPROVIDENCE ST VINCENT MEDICAL CENTERUTAH VALLEY REGIONAL MEDICAL CENTERSUTTER MEDICAL CENTER OF SACRAMENTODENVER HEALTH MEDICAL CENTERPSI 12 Post Operative PE or DVTLowest RatesLOGAN REGIONAL HOSPITALSUTTER AUBURN FAITH HOSPITALSUTTER SOLANO MEDICAL CENTERPARK CITY MEDICAL CENTERSUTTER DAVIS HOSPITALHILLCREST BAPTIST MEDICAL CENTERRIVERTON HOSPITALVALLEY VIEW MEDICAL CENTERESPANOLA HOSPITALSUTTER TRACY COMMUNITY HOSPITALPharmacy Patient SafetySeptember 23, 2014Jason Trahan, Pharm.D.Director of Pharmacy Medication SafetyPresentation OutlineFocus on Pharmacist involvement in two of ten patient safety areas:Adverse Drug EventsUse of DataVancomycinResponse to current literatureFentanyl PatchesHaloperidol Intravenous UseInjuries from FallsResponse to current literatureZolpidem 16Adverse Drug EventsChanges evaluation from facility specific to enterprise-wide in 2013.Increased usefulness of data and trendingReported Quarterly at enterprise and facility meetings.
17Talk about REPORTING RATE as opposed to actual rate of events.1718
Vancomycin actually #2 on list when both entries are combined and investigational that some may be avoidable events.
Contrast agents reviewed Iopamidol manly related to rash. No prior contrast agent allergy noted for patients. Reviewing utilization across enterprise demonstrates incidence rate to that reported in literature.Gadobutrol GI Side Effects, mainly nausea/vomiting. Incidence in line with reported literature. Radiology across enterprise has a great reporting culture.
Warfarin were mainly reported with events Prior to Admission.
Ceftriaxone Pruritis was majority no previous patient history of cephalosporin allergy
Vancomycin Red Man Related reactions reported. Enterprise infusion practices analyzed. 18VancomycinFacility 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.
19Proactive Use of DataFacility 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.
20Response to Current LiteratureFentanyl Patch DisposalFDA 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 PlanOutpatientInpatient
21Action PlanFentanyl Patch DisposalOutpatient Baylor Health Enterprises PharmaciesPharmacists Utilizing standardized teaching tool emphasizing disposalTool can be found: www.ismp.org/AHRQ/default.aspInpatient CareNursing Education for Fentanyl, Fold, and FlushConsistent message across continuum of care2223
http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/UCM337803.pdfThere are questions related to the flushing of medications refer to the FDA link for a list if meds considered appropriate for flushing.23Haloperidol UseSociety of Critical Care MedicineRevised Guidelines Published January 2013Prior 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
24Haloperidol UseAction Items:Removed from Enterprise ICU Delirium Order Sets.Recommended that patients receiving via the intravenous route of administration considered for telemetry monitoring.25ZolpidemJournal 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 2013FDA Requires lower recommended doses
26Zolpidem Action Plan:Electronic Health Record ChangesRevise order sets to remove pre-selection of prn insomnia medication.Dose revision to remove 10 mg ordering optionOnly 5 mg on order setsRemoval of 10 mg order sentence for quick ordering2728
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 hypoglycemiaApply current, evidence-based guidelines for individualizing glycemic target goalsAdopt 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