Intermountain Healthcare was recently recognized by the Patient Safety Movement Foundation for its success in reducing adverse drug events, having cut them by 10 percent in 2014. Our approach combines technology – applied, updated, and adapted to this task – with vigilant monitoring and strict compliance.
Our implementation of this approach may well be instructive to others addressing the same challenge.
Adverse drug events are injuries resulting from drug-related medical interventions that typically occur when a patient has an unexpected reaction to a medication. At Intermountain Healthcare, our electronic medical records system warns of drug incompatibility – between a patient allergy and a medication, for example, or between conflicting medications. Our approach to reducing adverse drug events goes far beyond that but builds on the same premise: that our programming should make it easy for the clinician to do the right thing and hard to do the wrong thing.
Our systematic efforts to prevent adverse drug events focus on three key interventions:
The first involves applying bar-coded medication administration (BCMA) with strict compliance. With this technique, a nurse bar codes both the patient ID band and the medicine to ensure its appropriate administration and that the "5 Rights" are applied: the right patient receives the right medication, via the right route, with the right dose, at the right time. At Intermountain Healthcare, we are very strict about compliance. We monitor it down to the individual clinician level, which is very unusual. We track every override of the BCMA process, and we require any clinician who overrides it to explain that action. This has reduced our override level to about 0.3 percent.
In addition, we look for patterns of overrides, exploring how and why they occur. If a pattern involves a particular individual, we determine the problem and how to fix it. Monthly we review the top 20 medications involved in overrides and look for common causal factors such has faulty barcodes and work to resolve those issues.
The second intervention involves the use of "smart" infusion pumps. When a medication is infused directly into the blood stream, the nurse selects the medication, the dosage, and the infusion rate programmed into the pump library, and the pump controls its safe administration. Database libraries provide the programming on which safe administration is based, and keeping the libraries up-to-date is crucial. Intermountain Healthcare, therefore, employs a full-time pharmacist to manage those libraries, track new medications as they emerge, and ensure that the latest medications are properly available. We apply the same clinician-level accountability to the use of the smart pump libraries as we do BCMA and resolve issues identified from trended data and the results of investigations when an individual chose not to use the programmed library.
The third intervention is an extraordinary tool created by Intermountain Healthcare and now used by all 22 of our hospitals. It's called the Adverse Drug Event Trigger Tool, and our electronic medical records system has been adapted to accommodate it. The Trigger Tool looks at every medication that has been administered across the hospitals, incorporates lab results at the individual patient level, examines trends that emerge, and triggers reviews when concerns merit them. It might identify, for instance, that Vitamin K was administered to counteract a particular anti-coagulant triggering a dosage review. In so doing, it's able to identify concerns, improve practices, and prevent problems before they arise or are exacerbated.
Developments in all three of these interventions are reviewed monthly. Data on the first two are distributed through a reports portal to key leaders who can drill down as needed. For compliance with bar-coded medication administration, for instance, individual clinicians can be shown how their performance compares to peers.
Intermountain's Medication Safety Committee reviews emerging triggers every month and looks for opportunities for improvement based on evident trends. The Committee often creates targeted work groups to explore and address trends of particular interest.
The Committee itself is composed of about 25 people at the system level, reflecting a wide range of related disciplines including, among others, pharmacy, nursing, radiology, surgical services, and anesthesia. The work groups are similarly multi-disciplinary, based on the focus of the effort needed for improvement.
It takes creativity, rigorous monitoring, and diligent analysis to reduce adverse drug events, but the results are especially meaningful and potentially life-saving. In just the last six months, our efforts have spared 485 patients from potential harm – a 25% reduction from our 2014 rate. Constant improvement is the result, and that demonstrable improvement is the inspiration for our continuous work going forward.
The author is Assistant Vice President for Quality and Patient Safety at Intermountain Healthcare, the not-for-profit health system based in Salt Lake City, Utah.
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