wimon anansakunwatt, uraiwan silpasupagornwong, umporn yoobang, naruemon dhana, monwarat...
TRANSCRIPT
Wimon Anansakunwatt,
Uraiwan Silpasupagornwong,
Umporn Yoobang,
Naruemon Dhana,
Monwarat Laohajeeraphan
INTERVENTIONS TO IMPROVE INTERVENTIONS TO IMPROVE MEDICATION SAFETY IN A MEDICATION SAFETY IN A UNIVERSITYUNIVERSITY HOSPITAL IN THAILANDHOSPITAL IN THAILAND
Adverse Drug Events were found a major complication for hospitalized patients and most of them were preventable.
Interventions were implemented in Siriraj Hospital during the year 2000-2010 Medication error (ME) reporting system Drug Information Service and Poison Control Center
(DIS&PCC) Adverse Drug Reaction (ADR) monitoring Staff education Patient education programs
No study to compare and conclude the success factors
Problem Statement
To study common success factors of interventions to improve medication safety during 2000-2010
Objective
Design
Observational descriptive study
Setting
Siriraj Hospital, the 2,300 beds tertiary-care teaching hospital of Mahidol University, Thailand
Interventions used for medication safety improvement in the hospital during 2000 to 2010
Reports and minutes of team meeting review Discussion with key persons of each team
Study population
Methods
Number of ME reportsADR prevention reportsPhone calls to DIS&PCCScore of test in education programsFactors influenced success of interventions
Outcome measures
Intervention: changing from 8 hour
service to 24 hour service
including toxicologist as consultants
providing staff education programs
Result: DIS&PCC received more
phone calls from 2,057 calls in 2005 to 20,054 calls per year in 2010
Drug Information Services (DIS) and Poison Control Center (PCC) Initiation
0
500
1000
1500
2000
2500
3000
ADR
Availability
Compat./Stab.
Cost
Dosage/Adm.
Herbal/Conv.med
Identification
Interactions
Law/Policy
Phar.kinetics
Pharmaceutics
Preg.& Lact.
Ther.use/Efficacy
What do they want to know?
Intervention: computerized alert in
pharmacy prescription processing
promoted asking patients a prime question for known allergy
Result: could prevent more
repeated known allergy cases from 152 cases to 3,139 cases per year
Adverse Drug Reaction (ADR) Monitoring Program
ADR pink label on inpatient’s chart
Note to nurse is printed in prescription processing
Red wrist band for patient with known allergy
Note to pharmacist is printed in prescription processing
ADR pink label on outpatient’s chart
Intervention: the manual reporting was
changed to on-lined system
gathering manual monthly reports from nursing and pharmacy department to risk management office
Results: Medication Error reporting
increased significantly (p<0.05)
Reports were used for communication and error prevention.
Medication Error Reporting
Pharmacist’s note to prescriber
Pharmacy newsletter
Color strips were used to distinguish look-alike packaging
Intervention: Staff education programs were
provided Results:
scores were significantly increased from pre-test to post-test
• 68.1% to 88.7% in high alert drugs (HAD) training (N= 312)
• 63.5% to 81.8% in drug administration training (N= 242)
0
10
20
30
40
50
60
70
80
90
HAD drug admin
Pre
post
Staff Education Program
Intervention: Patients were
empowered to use their medicines correctly and monitor themselves
Results: Patients increased their knowledge scores from 29% to 55%
(N=70, p<0.05) in transplantation clinic
from 58.60% to 93.33% (N=1,502, p<0.05) in anticoagulation clinic
Patient Education Program
There were the terms of standards quality accreditation survey multidisciplinary computer program counseling education in the meeting minutes and
discussions
Key persons of each intervention worked after office hours to improve the interventions
Results from Staff Interview
Common success factors of interventions to improve medication safety are:
Accreditations from external organizations Multidisciplinary team approach Using information technology Patient participation Devoted personnel
What we have learned from this study:
RecommendationEnhancing these success factors in interventions is valuable to improve medication safety
Economic outcome studies of these interventions are suggested
THANK YOU FOR YOUR ATTENTIONTHANK YOU FOR YOUR ATTENTION