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Improving Patient Safety Using Improving Patient Safety Using

Improving Patient Safety Using - PowerPoint Presentation

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Uploaded On 2018-11-21

Improving Patient Safety Using - PPT Presentation

Health Information Technology Eric G Gayle MD FAAFP IFHBronx R egional Medical Director and Regina Ginzburg PharmD Clinical Pharmacy Faculty BI Family Medicine Associate Clinical Professor St Johns University ID: 731430

medication patient electronic drug patient medication drug electronic documented risk active errors review safety chart women prescribing ehr adr

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Slide1

Improving Patient Safety Using Health Information Technology

Eric G. Gayle, MD F.A.A.F.P

IFH-Bronx

R

egional Medical Director

and

Regina Ginzburg,

Pharm.D

.

Clinical Pharmacy Faculty, BI Family Medicine

Associate Clinical Professor, St. Johns UniversitySlide2

Medication Errors & Preventable Adverse Drug Events

At least 1.5 million preventable ADEs occur each year in the United States

~1/3 occur in the outpatient setting

Cost per preventable ADE: ~$2,000National annual cost: $887 millionThe numbers above are likely an underestimation!

Preventing Medication Errors: Quality Chasm Series

http://www.nap.edu/catalog/11623.htmlSlide3

Electronic patient records and patient safety

communication

“Electronic pharmacy”

capabilities

EHR

Point of care interactions

legibilitySlide4

Effective Error-Prevention Strategies

Improving Patient-Provider communication

Verify active medication list with each encounter

Review the name and purpose of the selected medication.Discuss when and how to take the medication.Discuss important and likely side effects and what to do about them.Discuss drug-drug, drug-food, and drug-disease interactions.

Review the patient’s role in achieving appropriate medication useSlide5
Slide6
Slide7

Improving patient safety using Health Information Technology

“Electronic Pharmacy” within the EHR

Eliminates transcription errors

Point of care checks and reviews

Electronic prescribing

Improves patient medication history documentationSlide8
Slide9
Slide10

Effective Error-Prevention Strategies

Electronic prescribingSlide11

Ways to Improve Medication Errors Using HIT

Auto-calculated dosing for special populations

Weight-based formula incorporated for certain medications

Correct dosage should appear in the directions field for specified patient weight must be documented in current encounterSlide12

Auto-calculated dosing: Impact of Intervention

Retrospective chart review looking rate of medication errors in our pediatric patients who were prescribed this medication before and after intervention

N=316 (Pre) and 224 (Post)

Number of medication errorsPre: 103 (32.7%)Post: 46 (20.6%) p=0.002

Significantly fewer strength overdosing errors in postintervention group

OR 0.431 (95% CI: 0.175-0.964) [p=0.028]

Ginzburg et al. Am J Health-Syst Pharm—Vol 66 Nov 15, 2009Slide13

Effective Error-Prevention Strategies

Access to evidence-based referencesSlide14

Patient Safety Management

Pharmacy and Therapeutics Committee

Develop medication-related policies

Review new drug information from FDA

Review and update medication formulary

Build “smartsets” within EHR to reflect policiesSlide15

P&T Committee

Monitor medication effects and risk for use

FDA warnings, latest guidelines/position statements, new major RCTs

Committee’s decision based on levelsLevel 0 – no actionLevel 1 – “Inbasket” to all providersLevel 2 - Inbasket + BPALevel 3 – advise HCP to cease prescribingSlide16

Monitoring Adverse Drug Reactions

Provider detects an ADR event

ADR diagnosis is entered during encounterPatient chart is flagged and sent to P&T

Pharmacist reviews chart and determines if ADR needs to be submitted to MedwatchSlide17

Impact of Best Practice Alerts (BPAs)

Effort to decrease prescribing teratogenic medications to women of reproductive age

Phase I

: chart review determining the degree of need679 electronic charts reviewedPrimary outcome measureabsence of a documented contraception plan

or

documentation that patient is low risk for pregnancy

Exclusion

: Active contraceptive on medication list, IUD documented under procedure section, hysterectomy documented in surgical historySlide18

Results of Phase I

 51.3% of women were prescribed a potential teratogen and were considered high risk for pregnancy

No easy way to see if discussion took place with patient regarding potential teratogenicity

Slide19

Implementation of BPA

BPA will alert providers that they are ordering a potential teratogen for a women who is b/w 14-49 y/o

Exclusion criteria

:Active contraceptive on medication listHas IUD documented under procedureHas hysterectomy documented in surgical historyHas pregnancy or abortion diagnosis Slide20

BPA link to “smartset”

Progress note to blow in. Provider can choose 1 of 3 notes

Discussed risk and benefits.

Patient is sexually active, current method of contraception is document.Patient understands risk if becomes pregnant. Patient is not currently sexually active. Patient understands risk if becomes pregnant. Patient is only sexually active with women.Link to contraceptive management diagnosisSlide21

Future needs to improve safety

How to improve integration of OTC meds/ supplements with the Patient’s EHR

Two way communication between providers and hospitals- Bronx RHIO project ongoing.

One patient one chart conceptSlide22

The Unmarked Territory…

More research is needed for ambulatory care areas using HIT!!Slide23

Questions???