Pharmacy News

Hospital Engagement Networks Report Successes in Decreasing Adverse Drug Events

[July 1, 2014, AJHP News]

Cheryl A. Thompson

BETHESDA, MD 17 Jun 2014—With data analysis for the federally funded program Partnership for Patients underway, some of its hospital engagement networks have reported reductions of more than 40% in the rate of adverse drug events (ADEs).

Dignity Health, based in California, reported a 65% decrease in the rate of hypoglycemia events.

The Tennessee Hospital Association reported an aggregate rate reduction of 62%.

The New Jersey Hospital Association reported a 59% reduction in the rate of patients who have an adverse outcome related to improper medication at any dose.

The Hospital & Healthsystem Association of Pennsylvania reported a 55% decrease in the rate of opioid-related ADEs.

The North Carolina–Virginia Hospital Association reported a 54% decrease in ADEs per 1000 patient days for the 25 hospitals most engaged in the voluntary learning network.

The Minnesota Hospital Association reported a 43% reduction in events resulting in an International Normalized Ratio exceeding 5.

Launched in April 2011 by the Centers for Medicare and Medicaid Services (CMS), Partnership for Patients set two year-end 2013 goals for participants: 40% reduction in preventable hospital-acquired conditions and 20% reduction in complication-related hospital readmissions, compared with 2010.

Matthew Grissinger attributed much of the Hospital & Healthsystem Association of Pennsylvania hospital engagement network’s success in ADE reduction to two assessment tools.

Those tools are "Opioid Knowledge Self-Assessment" and "Organization Assessment of Safe Opioid Practices." Both were developed by the Pennsylvania Patient Safety Authority and are available from
External Link.

The 11-question multiple-choice self-assessment was developed, Grissinger said, "to have people in hospitals realize they don’t really know what their own practitioners know about opioids."

Grissinger wears multiple safety hats. He is the ADE project leader for the hospital engagement network, manager of medication safety analysis for the Pennsylvania Patient Safety Authority, which is a state agency, and director of error reporting programs for the Institute for Safe Medication Practices.

The results of the self-assessment—completed by more than 1700 physicians, nurses, and pharmacists at 24 hospitals— "made people realize how unknowledgeable people are about opioids," Grissinger said.

The results also made clear the need to raise the level of education provided to health care practitioners who work with opioids.

"It was somewhat eye-opening to see how poorly some questions were answered," Grissinger said.

As for the organization assessment tool, "Right up front, it identified practices they weren’t even doing," he said.

For example, more than half of the 17 hospitals that used the tool in September to December 2012 did not have definitions of opioid-naive and opioid-tolerant patients in their pain management protocols, Grissinger reported last year. And nearly a quarter of the hospitals did not have pain management protocols at all.

The next calendar quarter, use of the opiate antagonist naloxone in opioid-prescribed patients at the network’s hospitals decreased by 24% from the baseline in July 2012, the Patient Safety Authority reported.

"I really believe that just being aware of safe practices you should consider having in place" can bring about change, Grissinger said.

To determine the rate of opioid-related ADEs for Partnership for Patients, the hospital engagement network used more than just the measure of naloxone use. Grissinger said the network also collected data on rapid response team calls related to i.v. opioid use and made use of the data that hospitals already must report to the Patient Safety Authority regarding serious opioid-related events.

Key to the success of the Tennessee Hospital Association hospital engagement network was its formation of a statewide coalition of pharmacists, according to Patrice Mayo, a vice president for the association’s Tennessee Center for Patient Safety.

Pharmacy directors from facilities in the association’s hospital engagement network belong to the coalition. And so do the pharmacy directors at the Tennessee hospitals that belong to the five other hospital engagement networks with representation in the state, Mayo stated.

The coalition, known as the Medication Use Safety Innovation Community, or MUSIC, includes representatives from the pharmacy schools in the state.

Mayo stated that the coalition "has been instrumental in establishing consensus on [ADE] measures and increasing participation."

Although ADEs decreased by 87% from January 2012 to August 2013, the number of hospitals reporting data to the network was "very low," Mayo stated. Fluctuation in the number of reporting hospitals caused large variations from month to month in the numerator and denominator of the measures. With a change to quarterly reporting and the work of the coalition, she reported, the aggregate ADE rate reduction was 62% from the first quarter of 2012 through the fourth quarter of 2013.

Shekhar Mehta, director of clinical guidelines and quality improvement at ASHP, said two outstanding issues affect the ability of the hospital engagement networks to report ADE rates.

"One of them is the actual definition . . . people are using for ADEs," he said.

Different facilities define and record ADEs differently, Mehta said.

"It’s hard to draw comparisons across facilities," he said. "But it’s a good starting point because they’re actually starting to get engaged into the whole process of accounting for adverse drug events while patients are in their system."

The other outstanding issue concerns the consequence of actively pursuing ADEs and preventing them.

As health systems build a lot of quality-improvement initiatives and projects to reduce ADE rates, Mehta said, "they’re also seeing increases just because people are more frequently reporting the ADEs."

"That causes a little bit of concern," he continued, "because all of a sudden you’ll have an administrator professional who’s in the health system see this huge increase in the number of ADEs. But in reality it’s just because more people are exposed to the importance of reporting it."

As part of estimating the national rate of hospital-acquired conditions in 2010 for Partnership for Patients, the Agency for Healthcare Research and Quality used measures from the Medicare Patient Safety Monitoring System.

The agency determined that six medications or medication classes—digoxin, hypoglycemic agents, i.v. heparin, low-molecular-weight heparin, factor Xa inhibitor, and warfarin—were associated with a total of 50 ADEs per 1000 discharges, with hypoglycemic agents accounting for more than half of those ADEs.


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