North Carolina/Virginia Hospital Engagement Network

(NoCVA HEN)

Reducing Adverse Drug Events

Partnership for Patients: Medication Safety Overview

NoCVA Hospital Engagement Network Medication Safety

Webinar April 16, 2013

Brian J. Isetts, RPh, PhD, BCPS

NoCVA Medication Safety Webinar

PRESENTATION OVERVIEW•Partnership for Patients Aims•Magnitude of Drug-related Harms •Urgent National Call to Action•Questions to run on:What is contributing to current results?What can you do in your hospital to accelerate improvement?

Reducing Adverse Drug Events

• Over one-third of Hospital Acquired Conditions are ADEs in the Partnership for Patients focus

• Most significant cause of injury/death in hospitals

• At least 1.5 million preventable ADEs each year

• Office of Inspector General - Report of Nov. 2010

• NEJM (Budnitz) 11/24/2011 – High impact ADEs

• AHRQ Brief #109 – ADE in1.9M hosp stays (2008)

• Joint Commission Standard MM 07.01.03

Medication Safety Focus

• Focus on reducing high impact medication harms related to anticoagulants, hypoglycemic agents, and opioids

• Reduce drug-related readmissions to improve care transitions

• Work closely with medication advisory groups in the Hospital Engagement Networks (HENs)

An Urgent National Call to Action:Getting a Little Help from our Friends

• Inventory of federal resources – Sec. Sebelius

• Expectations of Partnership for Patients results

• Federal Interagency Response to ADEs• External stakeholder engagement in our

work• Patient and family engagement in our

work• Partnership for Patients resources from

the evaluation and NCD contractors• ADE Road Map from the Minnesota HEN

A Glimpse of the HEN Response to the Medication Safety Challenge

• March 1, 2012 - there were 3 HENs and 200 hospitals engaged in medication safety

• April 2nd Webinar framed the challenge and established a vision for our journey

• July 15th the “gang of 7 HENs” took responsibility for reducing high-impact harms

• Jan. 9, 2013 - 3,084 hospitals in 24 HENs engaged in medication safety improvement; 1,493 committed to reporting; 211 sustaining ↓

Anticoagulation Management Service – Performance Data (Hosp. of Univ. of PA) Data

2007

4054

440

57540

60340

63440

66440

69540

72540

75640

787

0%

2%

4%

6%

8%

10% Percent of Patients with INR > 4

Inpatie...

Month

% o

f pat

ient

s w

ith IN

R >

4

Value Pre- AIM Team

Summary of Progress with Measurement Examples

• Everybody pulling in the same direction• Roadmap of Medication Safety Best

Practices• % of Patients on Warfarin with INRs > 5• % of Blood Glucose readings below 50

mg/dl• % of Patients on Opioids given Naloxone

• Help the HENs help hospitals• Using run charts to assess care

improvements in real time at the patient’s bedside

What more can be done?

• What is contributing to successful hospitals?

* CEO/CMO leadership in hospitals to engage all health team

members * Individual guidance for hospitals in

the science of rapid cycle quality improvement • What can you do to accelerate progress in

your hospital?