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Prevention of Adverse Drug Events

What is an Adverse Drug Event?  Any event, large or small, at any point in the medication system, from the time the drug is ordered until the patient receives it, is considered an adverse drug event (ADE).

 

What is a Medication Error?  Any preventable event that may cause patient harm or lead to inappropriate medication use while the medication is in the control of the healthcare professional, patient, or consumer is considered a medication error.  A medication error can be a mistake in any step of the medication management process or system (e.g. prescribing, dispensing, administering, or monitoring), regardless of the causes, and regardless of whether or not the error reaches the patient.  Medication errors are associated with 7000 deaths each year, as well as an annual cost of $2 billion dollars. (Source, Institute of Medicine).

 

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Prevention of Medication Errors

The Baystate Health (BH) practice model is dedicated to providing care to patients and ensuring safe and effective medication therapy.  BH remains committed to utilizing technology to assist in safe medication use processes.  Our goal is to design a collaborative medication use process across the health system that allows caregivers to do the right thing every time.  In an effort to accomplish this, we strive to effectively integrate state of the art automation, technology, and evidence-based science, while working continuously to improve the safety and efficiency of patient care.   Established technology systems in place at BH include a fully electronic medical record (EMR),  computerized provider order entry (CPOE) for both inpatient and ambulatory prescribing via the clinical information system (Cerner Millennium), bedside barcode scanning for patients and medications, PYXIS profile automated dispensing cabinets, electronic medication reconciliation, and ePrescribe to ensure appropriate transitions of care.

 

Highlights

Baystate Health

 

  • The prevention of medication errors is an important safety expectation for The Joint Commission whose vision is to continuously improve health care for the public.   The Joint Commission requires pharmacists to review all medication orders prior to administration. Each day pharmacists at Baystate Health review over 3,800 orders and collaborate with healthcare providers to ensure the most effective and safe medications are chosen for our patients.

 

  • Baystate Health has adopted “LEAN” philosophies which represents a fresh way to look at work systems within healthcare to improve quality of care. The fundamental principles of this approach are to develop innovative ideas to reduce waste in materials and labor while simultaneously increasing product quality. The cornerstone to achieve continuous improvement using LEAN principles is engaging all employees in the decision process.  Over the last year Baystate Health has implemented many sustainable LEAN projects that have improved medication safety and reduced cost for the health system. 

 

  • Medication safety is the number one priority for our employees and patients who use Baystate Health Ambulatory Pharmacies. Each day pharmacy staff members look for opportunities to improve patient safety by utilizing the online self-reporting safety reporting system (SRS).  A few examples to improve the safe dispensing of medications include: development of a look-alike-sound-alike medication list, standardized directions for pediatric oral liquids, triple checks of medication NDC codes during the dispensing process, removal of obsolete medications from our CPOE system, and staff education on best practices concerning medication safety.

 

  • Baystate Health has utilized a number of resources from The Institute for Safe Medication Practices (ISMP) to improve patient safety including:
    • 2011 ISMP Medication Safety Self Assessment® for Hospitals: a 270-item self-assessment for medication safety was conducted by Baystate Medical Center and Baystate Franklin Medical Center in September of 2011.
      • BMC:  Scored 80 % (benchmark for similar size hospitals 72 %)
      • BFMC: Scored 79 % (benchmark for similar size hospitals 69%)
    • 2012 ISMP International Medication Safety Self Assessment® for Oncology: started during the summer of 2012, this 175-item self-assessment for oncology safety is well underway at Baystate Health.  The interdisciplinary process is identifying opportunities to further coordinate and enhance safety systems for oncology patients.
    • ISMP Antithrombotic Safety Recommendations and Resources: Baystate Health has evaluated these and other resources to improve patient safety with antithrombotics, and has implemented:
      • A daily information system report to identify inappropriate duplicate anticoagulant therapy.
      • Revised Baystate Health Antithrombotic Practice Guidelines incorporating the latest American College of Chest Physician recommendations and newer antithrombotic modalities.
      • Anticoagulant Reference Card “Management of Oral Anticoagulation with Warfarin” to assist health care professionals when prescribing this medication. 
      • Providing warfarin drug therapy is challenging since it has a small range between toxic and sub-therapeutic doses and it exhibits variability in dose response among patients.  Baystate Health pharmacists play a key collaborative role in the management of warfarin therapy ensuring appropriate labs are ordered and monitored to provide safe, effective dosing for our patients. 

Over the last few years drug shortages have dramatically increased world-wide.  On a daily basis the pharmacy department works with other healthcare professionals to seek clinically appropriate drug treatment alternatives. A survey conducted by American Society of Health System Pharmacists (ASHP) indicates that hospital pharmacists are spending eight to twelve additional hours per week addressing medication shortages.  ASHP also estimated additional annual labor costs to US hospitals managing drug shortages to be $216 million.

 

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