The Case for Staying the Course: Adverse Drug Event Gap ......The Case for Staying the Course:...
Transcript of The Case for Staying the Course: Adverse Drug Event Gap ......The Case for Staying the Course:...
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The Case for Staying the Course:
Adverse Drug Event Gap Analysis Survey and
California Success Stories
California Society Hospital Pharmacist
November 2, 2013
Michele Davenport Lambert, Director CalHEN
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The California Hospital
Engagement Network (CalHEN)
• A Partnership for Patient’s initiative supported by the Centers for Medicare and Medicaid (CMS) to hospitals in 2012 and 2013.
• CalHEN is subcontracted with the Health Research, Education and Trust (HRET), a subsidiary of the American Hospital Association (AHA).
– AHA is contracted with CMS.
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Goals
• 1st Goal: o Engage hospitals to commitment to reducing hospital
acquired conditions by 40% and preventable readmissions by 20% by December 31, 2013 in order to attain CMS goals.
• 2nd Goal: o Accelerate and spread patient safety strategies
systematic with different implementation models across the United States.
o CMS funded 26 Hospital Engagement Networks (HENs).
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Hospital Acquired Conditions (HACs)
1) Adverse Drug Events (ADE) 2) Catheter Associate Urinary Tract Infections(CAUTI) 3) Central Line Associated Blood Stream Infection (CLABSI) 4) Early Elective Delivery (EED) 5) FALLS- with and without injury (FALLS) 6) OB Harm (OB) 7) Pressure Ulcers (PU) 8) Surgical Site Infections (SSI) 9) Ventilator Acquired Pneumonia (VAP) 10) Venous Thromboembolism (VTE)
11) Elective Readmissions (READ)
Project Overview: Harm Topics
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HRET Hospital Map
170
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California HEN Hospitals (170)
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The CalHEN Model
• Six Network Facilitators • Supports geographic defined area to provide:
o Technical support, coaching and consulting: o Principles and tools of process improvement o Test of change and spreading successful strategies o Evidence based strategies and tactics using HRET harm topic change packages
o Encourage and facilitate hospitals to share their lessons learned and
success stories to others to support their improvement o Collaboration with state, county, federal and private organizations to
affect hospital improvement to achieve patient safety goals
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• HRET o Collaborative in person and virtual education and hospital sharing calls o Listserv networking o Process Improvement Fellow Leadership training o CEO and Medical Leadership opportunities o Affinity Groups conference calls- rural/critical access, psy, LTC, OB and readmission and
medication management o Hospital Progress Improvement Reports o Hospital Progress and CEO Dashboard Reports on Progress
• CalHEN o Webinars on harm topics, PI principles and tools and patient and leadership engagement o Weekly Updates o Sharing Success Stories, cross pollination across the state o Community meeting collaboration with HSAG and Regional Hospital Associations o Small hospital group sharing calls targeted to discuss topic measure they are struggling with a
hospital that has been successful reducing harm o Hospital PI Team site visits and conference calls o Progress/AIM Reports
Opportunities To Discover, Learn, Share
and Spread Improvement Success
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Hospitals Reporting
By Harm Area and Readmission
* Represents reporting for December 2012 and September 2013
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Achievements in Level Of
Improvement Over Time
(September 2013)
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Adverse Drug Event High Risk
Gap Analysis Survey*
Anticoagulants
Opioids
Hypoglycemic agents
*Minnesota Hospital Association Medication Safety Road Map Prevention Strategies
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Eliminating ADE Harm
Medications are the most common intervention in healthcare but are also
most commonly associated with adverse events in hospitalized patients
At least 20% of all harm is associated with medication incidents
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Survey Questions
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Survey Question Categories
Standard policies & practices
Practice guidelines
Eliminate opportunities to create errors in prescribing, preparation, storage and dispensing
Hand-over/transition communication process
Education
• Staff
• Patients/family
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Responses to Five
Question Categories
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Opportunities To
Reduce Harm
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Hand-Over/Transition Communication
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Standard Policies & Practice
Management: Initiation and
Maintenance Therapy
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Standard Policies and Practices
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Standard Policies and Practices
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Standard Policies and Practices
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Standard Policies and Practices
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Standard Policies and Practices
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Standard Policies and Practices
Hypoglycemia
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Standard Policies and Practices
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Standard Policies and Practices
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Standard Policies and Practices
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Practice Guidelines
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Practice Guidelines
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Eliminating Errors: Prescribing,
Preparation, Storage
and Dispensing
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Eliminating Errors: Prescribing,
Preparation, Storage
and Dispensing
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Staff Education
• Add table
The facility provides interdisciplinary education: CalHEN Member Non-member
Initial training for new hires and existing staff 51/55 (92.73%) 46/60 (76.67%)
Post test incorporating a case-study approach to demonstrate proficiency 33/55 (60%) 32/60 (53.33%)
Plan for targeting gaps in knowledge 41/55 (74.55%) 23/60 (38.33%)
Ongoing education is provided 44/55 (80%) 41/60 (68.33%)
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Patient/Family Education
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Conclusion
Survey results show pharmacist have the opportunity to reduce patient harm when opioid and hypoglycemic medications are prescribed by:
• Developing policies and standard practices • Implementing practice guidelines • Participating in offering pain management alternatives to opioid
medication; if appropriate • Validate staff core competency in hospital standard practices
and guidelines for patients receiving opioid and hypoglycemic agents by using case study practice logic
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PHARMACIST COLLABORATIVE
CALL TO ACTION
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QUESTIONS
• http://www.calhospital.org/Anticoagulation-gap-analysis-sharing-call
• http://www.calhospital.org/Hypoglycemic-GAP-analysis-
sharing-call • http://www.calhospital.org/Opioid-GAP-analysis-
sharing-call
For more information on the California Hospital Engagement Network and ADE statewide improvement contact us: Email: [email protected] Phone: ( 916) 552-7617
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Introductions
California Adverse Drug Event
Success Stories
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Salinas Valley Memorial Healthcare
Salinas, California
Presented by
Larry Dolph, Pharm D.
Director of Pharmacy
Glycemic Control Initiative
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Doctors Hospital of Manteca
Manteca, California
Presented by
Kathy Marconi Pharm D. Director of Pharmacy
Director of Clinical Quality*
(*Risk Management, Joint Commission, Coordinator and Performance Improvement Director)
Reduction of Adverse Drug Events
with Harm: MERP Survey Measure