110719 Webinar #3 - FINAL...

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Partnership for Patients-National Priorities Partnership©

Patient Safety Webinar Series

Webinar #3: Preventing Adverse Drug Events in Your

Organization

J l 19 2011July 19, 2011

Today’s Hosts and SpeakerModerator Bernie Rosof, MD, Chairman, Board of

Directors, Huntington Hospital, North Shore-Long Island Jewish Health System, NPP Co Chair

© National Priorities Partnership

NPP Co-Chair

Featured speaker Michael Cohen, MS, ScD, RPh, President,

Institute for Safe Medication Practices

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Today’s Reactor Panel

Steven Meisel, PharmD, Director of Patient Safety, Fairview Health Services

David Bates, MD, MSc, Chief Quality Officer Brigham and Women’s Hospital


Officer, Brigham and Women s Hospital Bob Galvin, MD, MBA, Chief Executive

Officer, Equity Healthcare, The Blackstone Group

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Welcome to the Patient Safety Webinar SeriesThe objectives of the series are to:

Share strategies for “getting started” to accelerate improvements in national patient safety efforts


safety efforts

Highlight the role of public-private partnership in achieving Partnership for Patients goals

Describe the role of the NPP in catalyzing action and enabling change

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Objectives for Today’s Webinar

Provide an opportunity for thought leaders in the field of adverse drug events to share best practices, success stories, and strategies for getting started

© National Priorities Partnership© National Priorities Partnership

Generate action in organizations and communities nationwide

Provide examples of public-private partnerships working collaboratively to achieve results

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About the Audience

© National Priorities Partnership6

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Audience Regional Location


Polling Question

Which demographic best describes your organization or community?


g y

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Developing a National Quality Strategy

Health reform legislation, the Affordable Care Act (ACA), requires the Secretary of Health and Human Services to “establish a national strategy to improve the delivery of healthcare services, patient health outcomes, and population health.”

HR 3590 §3011, amending the Public Health Service Act (PHSA) by adding §399HH (a)(1)


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HHS’ Domains and Principles for the National Quality Strategy

Principles reflect: Patient-centeredness and

family engagement Quality care for patients of

all ages, populations, i l ti d

BETTERCARE

service locations, and sources of coverage

Elimination of disparities Alignment of public and

private sectors

10© National Priorities Partnership

AFFORDABLECARE

HEALTHY PEOPLE/

COMMUNITIES

HHS 2011 National Quality Strategy:Six National Priorities

1. Making care safer by reducing harm caused in the delivery of care.

2. Ensuring that each person and family are engaged as partners in their care.

3. Promoting effective communication and coordination of care.4. Promoting the most effective prevention and treatment practices

for the leading causes of mortality, starting with cardiovasculardisease.

5. Working with communities to promote wide use of best practices to enable healthy living.

6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.


NPP has been specifically asked to provide input to HHS on identified priorities as well as at least:

NPP’s Ongoing Role in Consultation to HHS on the National Quality Strategy

three goals per priority area two strategic opportunities per goal two measures per goal


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Partnership for Patients Goals

Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40%compared to 2010.

Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20%compared to 2010.

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Partnership for Patients Nine Areas of Focus

Catheter-Associated Urinary Tract Infections

Central Line Associated Blood Stream Infections

Pressure Ulcers Surgical Site Infections Venous

ThromboembolismBlood Stream Infections Injuries from Falls and

Immobility Obstetrical Adverse

Events

Thromboembolism Ventilator-Associated

Pneumonia Adverse Drug Events

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Partnership for Patients Adverse Drug Events

Goal: Hospitals will reduce preventable adverse drug events by 50% by 2013 Over adverse drug events by 50% by 2013. Over

three years, this would prevent 830,000 ADE’s.

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How Will Change Actually Happen?

And how will it happen at And how will it happen at scale?

How Will Change Actually Happen? There is no “silver bullet,” but we know we

must:

work together provide thoughtful incentives provide thoughtful incentives engage patients and families, authentically engage leadership assist in the painstaking work of improvement

Approaches to Preventing Adverse Drug Events in Health Systemsy

Michael R. Cohen, MS, ScD, RPhPresident

Institute for Safe Medication Practices

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Sources of Information

Staff Voluntary reporting; paper, hotline, or online

reports “Good Catch” programs Staff meetingsPatients

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Patients Satisfaction surveys Focus groups Patients instructed to “SPEAK UP”

Patient is partner/patient pledge

Group or individual visits to other locations


Proactive Risk Assessment

Medication safety self assessments External sources

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Patient Safety Organizations ISMP-ASHP-NCCMERP National Alert Network

Leadership walk arounds

ISMP Medication Safety Self Assessment

ISMP Medication Safety Self Assessment® for Hospitals 2011 Self Assessment

Automated Dispensing Cabinets

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p g Antithrombotic Therapy Bar Coding Self Assessment Community/Ambulatory Pharmacy Physician Practices

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External Sources of Risk Identification

Error reporting programs TJC sentinel event alerts FDA

ISMP National Medication Error Reporting Program FDA MedWatch program FDA Patient Safety news

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at e t Sa ety e s

PA-PSRS ISMP QuarterWatch and Quarterly Action Agenda

Professional publications ISMP publications Patient safety journals

Knowledgeable consultants

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www.patientsafetyauthority.org

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www.accessdata.fda.gov/psn/

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Concurrent Risk Assessment

Pharmacy Interventions (clinical or dispensing staff)

Nursing Interventions

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Nursing Interventions Direct observation (AU MEDS)

(http://www.medaccuracy.com/) - Barker, et. al., Auburn University

Triggers and markers

Retrospective Risk Assessment Data from technology Overrides of automated dispensing cabinets CPOE and pharmacy system alerts Smart pump data Bedside scanning data etc


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Bedside scanning data, etc. Chart reviews Internal voluntary reporting Share information about errors that happen within

department and corrected! IHI trigger tool Review of aggregate RCA data

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Sharing and Learning

Safety newsletters to staff Work with your Patient Safety Organization Partnership for Patient Safety Collaborative projects with stakeholders in your

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p j yarea Project in Philadelphia area to make use of

HYDROmorphone safer

Importance of Consumer Involvement


Importance of Consumer Involvement

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HYDROmorphone Experience

Equianalgesic potency to morphine not understood

Orders for excessive doses and/or short intervals between doses

Opioid naïve status is often not consideredO h i ifi ib i f Other significant contributing factors are not being appreciated: Patient’s age, respiratory disease, concomitant

therapy with other opioids, benzodiazepines, etc. Lack of patient monitoring Actions taken

Available at www.ismp.org

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Key Questions for the Audience

1. What has your organization done to reduce adverse drug events? What have you found to be the most effective approach?

2. In your experience, what were the barriers to


implementation and keys to success?

To provide comments, please type into the chat box at the bottom of your screen or

dial 1-888-857-6930 (confirmation code 9987491).

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Polling Question

Do you have a system in place for identifying vulnerable populations at risk of adverse drug


p p gevents?

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Polling Question

What are you currently doing to follow up with patients to minimize adverse drug

events?


events?

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Reactor Panel Discussion

Moderated by Bernie Rosof


NPP Co-Chair

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Frontline Provider Perspective

Steven Meisel, PharmDDirector of Patient SafetyFairview Health Services

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Health System Perspective

Steven Meisel Pharm DSteven Meisel, Pharm.D.

Director of Patient Safety

Fairview Health Services

Minneapolis, Minnesota

Harm vs. Error

Potential Adverse Events

Preventable Adverse Events

MedicationErrors

Adverse Drug Events

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Strong Organizational Leadership &

Culture

P ti t

Build Adaptability, Resilience, &

Teamwork

Deploy Known Best Practices & Design New Best Practices

Patient

Safety

Training

Total reports are down 40.3% from 2007 to 2010 and 13.3% from 2009 to 2010.

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*100% review of triggers associated with anticoagulants, narcotics, sedatives, and antidiabetic agents. Other ADEs not

included.

15% reduction from 2009

Frontline Provider Perspective

David Bates, MD, MScChief Quality Officer

Brigham and Women’s Hospital

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MD

Pharmacist

Impact on Serious Medication Errors

Med Ordering

Transcription

OrderingErrors (49%)

TranscriptionErrors (11%)

Order Entry &decision support‐55% reduction

PharmacyBarcoding‐

RN Patient

Medication on Wards

MedicationAdmin Record

Dispensing

Administration

DispensingErrors (14%)

AdministrationErrors (26%)

Errors (11%)

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Barcoding67% reduction

‐eMAR/barcodingat bedside‐ 51% reduction

eMAR‐100% reduction

CPOE Cumulative net savings were $16.7 million over 10 years, and net

operating $9.5 million [Kaushal, JAMIA, 2006] Leading contributors

Renal dosing guidance Tools to help nurses Specific drug guidance Adverse drug event prevention

Financial Impact of Interventions

Barcoding At time of dispensing [Maviglia, Archives Int Med 2007]

5-year cumulative costs = $2.3M $1.4M one-time investment (pre go-live, first 2 years) $343K/yr recurring (post go-live, last 3 years)

5-year cumulative benefits = $5.5M 5-year cumulative net benefit = $3.3M Break-even within 1st year after go-live

At point of care

Healthcare Purchaser Perspective

Bob Galvin, MD, MBAChief Executive Officer

Equity Healthcare, The Blackstone Group

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Employer/Purchaser Thoughts on ADE’s

Why employers care◘ Healthy, productive employees◘ Value of healthcare spend◘ Want to trust the healthcare system

Hits close to home◘ Aerospace….fuselage cracks due to mis-aligned rivets

Challenger o-ring: lack of low temperature testing

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Challenger o ring: lack of low temperature testing◘ Entertainment…Spiderman falls due to improperly rigged harness

Healthcare more complex but both sides can learn from each other◘ Build quality into design◘ Usable continuous feedback◘ Redundant systems◘ Root cause analysis ◘ Culture and communication

Employer Role

Support Safety agenda

◘ All major employer groups have signed onto Partnership for Parents

Use tools we have – create external environment that supports safety efforts

◘ Transparency to employees/families Leapfrog Group CPOE one of three initial leaps Insist on public disclosure Annual survey drives accountability

◘ Purchasing leverage – focus on payment reform

CPR (Catalyst Payment Reform) - new employer non-profit group

Influence insurers to pay for quality

Push for e-prescribing: meaningful use criteria, adoption of Bridges to Excellence, etc

Adopt Medicare payment changes on re-admission, other avoidable errors

New payment models should reward safety

Make dollars available for investments in QI

Make business case to hospital leaders that allocating dollars to quality is in their financial interest

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Questions for the Panelists

From your perspective, how would you manage these high-risk scenarios:

An elderly patient taking 12 medications, prescribed


y p g pby 4 different specialists?

A patient who does not adhere to taking all his medications exactly as prescribed?

A patient who speaks English as a second language?

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Questions for the Panelists

What is your advice for webinar participants who want to accelerate change and achieve success?


What policy or environmental supports are needed to accomplish your goals?

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Discussion with the Audience

Please use the chat box at the bottom of your t d t ti t th


screen to send a comment or question to the moderators, or dial 1-888-857-6930 (confirmation

code 9987491).

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Polling Question

Have you experienced recent success with reducing adverse drug events in your


organization?

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Polling Question

What tools are you currently using to reduce adverse drug events?


reduce adverse drug events?

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Audience Discussion Questions

1. What changes in your payment system would make it easier for you to accelerate success in reducing adverse drug events?


success in reducing adverse drug events?

2. How do you identify and measure adverse drug events in your organization?

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Audience Discussion Questions

3. What do you do in your organization to actively engage each patient in his or her care?


care?

4. What action might you take based on what you heard today?

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Polling Question

When do you plan to act on the


information provided in this webinar?

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Polling Question

Did you find tangible actions and practices you can put to use in your organization or

it i thi bi ?


community in this webinar?

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Conclusion

Next Steps, Further Resources, and C l di R k


Concluding Remarks

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Further Resources

Partnership for Patients website:

www.healthcare.gov/center/programs/partnership/index.html

National Priorities Partnership website:

www.qualityforum.org/Setting_Priorities/NPP/National_Priorities


_Partnership.aspx

National Quality Forum patient safety webpage:

www.qualityforum.org/Topics/Safety_pages/Patient_Safety.aspx

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Patient Safety Webinar SeriesUpcoming webinar topics:

Infections in Intensive Care Units – August 3 Surgical Site Infections – August 16

P Ul d I j i f S t b 9


Pressure Ulcers and Injuries from – September 9 Obstetrical Adverse Events – September 28 Venous Thromboembolism - October 5

To register: eo2.commpartners.com/users/pfp/

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Concluding Remarks

Michael Cohen, Featured Speaker


Bernie Rosof, NPP Co-Chair

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Thank YouA recording of this webinar will be available on the

National Quality Forum website within 48 hours. When


Q yyou exit, you will automatically be directed to an

evaluation about this webinar.

For further questions, please contact [email protected]

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110719 Webinar #3 - FINAL...

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