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Material Released to Help Hospitals Reduce Preventable ADEs

Cheryl A. Thompson

The public–private effort to make health care safer for patients received assistance on November 29 with the release of a road map for the creation of a comprehensive hospital-based medication safety program.

Accompanying the road map are gap analyses specific to adverse events resulting from the use of anticoagulant agents, hypoglycemic drugs, and opioids.

All the material was created by the Minnesota Hospital Association, one of the hospital engagement networks under contract with the Centers for Medicare and Medicaid Services (CMS) to support Partnership for Patients.

Partnership for Patients has a target date of year-end 2013 for decreasing the number of preventable hospital-acquired conditions, including adverse drug events, by 40% and reducing hospital readmissions by 20% from what they were in 2010.

The 26 hospital engagement networks, according to CMS, must teach and support hospitals in making care safer, provide them with technical assistance, and implement a system to monitor their progress.

Measures. This past December, 742 hospitals were submitting data on adverse drug events through the hospital engagement networks, according to the contractor evaluating the project.

Fewer than one in five of those hospitals showed improvement or had sustained their earlier high performance, the contractor reported.

Aside from the 742 hospitals, the contractor also reported, 2304 hospitals were working on the issue of adverse drug events and some had committed to reporting data.

Steve Meisel, director of patient safety at Minneapolis-based Fairview Health Services, said hospitals face a challenge in measuring adverse drug events.

Basically, said Meisel, a member of the advisory group that developed the road map and gap analyses, there is not a good definition of adverse drug event that also has appropriate exclusion and inclusion criteria.

A high International Normalized Ratio (INR), for example, does not always signal an adverse event from anticoagulant therapy, he said. That high INR could be the result of something other than drug therapy, such as severe liver disease or malnutrition.

Similarly, a low blood sugar concentration does not always signal an adverse event from insulin therapy, he said.

And if a dose of naloxone has no effect on a patient, then the cause of concern is not an adverse effect of a narcotic.

The road map includes a three-part item about the hospital having processes in place to track the number of patients with an INR of >5, number of patients with a blood glucose concentration of <40 mg/dL, and number of naloxone administrations. Alternative identifications of adverse drug events are allowed but not offered.

"We’re not looking at creating a perfect adverse-drug-event metric," Meisel said. "We’re looking at a metric that we can track over time to track improvement. . . . We want people focusing on clinical care and quality improvement as opposed to sitting there poring through charts and worrying about metrics."

Improvement can be tracked by means of these imperfect measures, he explained, because each measure’s error rate is constant for a specific hospital. A hospital that has patients with high INRs for reasons other than warfarin therapy will likely have those types of patients in six months, for example.

"So, if you do your improvement work on Coumadin [warfarin], then that will be reflected in the rate of improvement overall, but you won’t get to 0" per 1000 patient-days, Meisel said.

Road map, gap analyses. Nora Vernon, the Minnesota hospital engagement network’s patient safety and quality specialist, said other networks had been "eagerly awaiting" the release of Road Map to a Medication Safety Program.

Since its release, Vernon said, she and Meisel have been talking about the road map to a national audience.

The road map offers 16 specific actions and 82 items for audit.

Its content, the road map declares, comes from published literature and guidelines by relevant professional organizations and regulatory agencies and best practices identified by the hospital association’s Adverse Drug Event Advisory Group.

Pharmacists constitute more than half of the advisory group.

Anticoagulation Agent Adverse Drug Event Gap Analysis covers oral agents and injectables, as does Hypoglycemic Agent Adverse Drug Event Gap Analysis.

Opioid Adverse Drug Event Prevention Gap Analysis covers oral, injectable, transdermal, and transmucosal opioid-containing medications.

The road map and gap analyses are available from

Meisel said some of the elements in the road map, such as a pain management stewardship program and hydromorphone-syringe repackaging, are intended to be provocative.

Soon to be released is a gap analysis specific to the prevention of venous thromboembolism (VTE), Vernon said.

Included in that analysis, she said, is a series of questions as to whether a hospital has in place certain processes, such as assessment with evidence-based criteria of all patients for their risk of VTE on admission, a change in the level of care, and discharge.

Tania Daniels, the hospital association’s vice president of patient safety, said the hospital engagement network has tracked process-of-care measures for VTE prevention and is in the "beginning phases" of analyzing data on a related outcome-of-care measure.

That measure, she acknowledged, is Agency for Healthcare Research and Quality patient safety indicator 12, "postoperative pulmonary embolism or deep vein thrombosis."

Partnership’s goal. At the launch of Partnership for Patients in April 2011, the Department of Health and Human Services said about 1.9 million adverse drug events occur annually in patients in hospitals.

Half of these adverse drug events, according to a departmental study released in November 2010, are preventable.

Partnership for Patients set its sights on eliminating 50% of those preventable adverse drug events by year-end 2013.

ASHP pledged its commitment to Partnership for Patients from the start.

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