1. Courtesy Reminders: During the webinar, you may select *7 on your phone to speak, and use *6 to mute. Please refrain from placing the phone on HOLD during the presentation.    April 27, 2016    Tom Kaster WHA Improvement Advisor Breaking the ADE Trigger Code

2. Action Items 1.What are we trying to improve? 2.How are we going to measure improvement? 3.How are we going to assist with getting the data? 4.How are we going to get there? Today’s Call

3. What are we trying to improve? Adverse Drug Events Due to: – Opioids – Anticoagulants – Insulin

4. Why does this matter? In 2011, U.S. Department of Health and Human Services found that 30% of inpatients experienced an ADE AHRQ estimated that drug-related adverse events occurred in nearly 1.9 million inpatient stays Preventable ADEs were estimated to cost $3.5 billion in 2006

5. So…how do we measure this? The Institute for Healthcare Improvement (IHI) – The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. – Founded by Don Berwick IHI Trigger Tool for Measuring Adverse Events – The use of "triggers," or clues, to identify adverse events (AEs) is an effective method for measuring the overall level of harm in a health care organization. – Includes known AE triggers Basically if “A” happens or is used it is an indicator that an adverse event may have happened

6. IHI Triggers for Opioids/Anticoag/Insulin

7. Past Obstacles to Measurement So many variables – Different ways to pull data – Different EHR’s – Different patient types Hard to “get” to the data

8. Overcoming Those Obstacles Steering Committee – Pharmacy Directors Systems Across the State – Informatics Experts at Those Hospitals – Some Guidance from EHR’s A Special Champion – Dalia Saleh, PharmD PGY2 Health-System Pharmacy Administration Resident Aurora Health Care

9. Contributors included: ADE Steering Committee

10. Guiding Principles of the Steering Committee As ERH Agnostic as possible Data is for improvement not regulatory Don’t let perfect be the enemy of good – Trying to capture 80% of events – Knowing there will be some white noise

11. Goals of the Steering Committee Review IHI Trigger Guidance Come to a group agreement of most effective way to obtain measures Provide EHR specific tips and suggestions when available Provide guidance on how to stratify and analyze data for improvement Eventually help present strategies for improving measures

12. MonthTopic April 27Introduction to WHA 2016 ADE Improvement Initiative for Hypoglycemics, Anticoagulants, and Opioids May 25Obtaining IHI Trigger data for Opioids and Anticoagulants June 17Special Webinar with Dr. Steve Tremain-Cynosure Health: ADE Improvement Strategies July 27Obtaining IHI Trigger data for ADE with Insulin / Improvement strategies for Insulin Related ADE’s WHA is launching a 4 month improvement initiative running April through July Plan of Action

13. In the meantime… Build your team – Pharmacy – Nursing – Informatics – Frontline – PFA

14. Start thinking about improving strategies ADE Top 10 Checklist – http://www.whaqualitycenter.org/Portals/0/Partn ers%20for%20Patients/ADE/Adverse%20Drug%20 Events%20Top%2010%20Checklist.pdf http://www.whaqualitycenter.org/Portals/0/Partn ers%20for%20Patients/ADE/Adverse%20Drug%20 Events%20Top%2010%20Checklist.pdf ADE Gap Analysis – http://www.whaqualitycenter.org/Portals/0/Partn ers%20for%20Patients/ADE/References%20and%2 0Tools/ADE.docx http://www.whaqualitycenter.org/Portals/0/Partn ers%20for%20Patients/ADE/References%20and%2 0Tools/ADE.docx

15. Introducing Beth Dibbert, WHA Quality Director – ADE Improvement Advisor bdibbert@wha.org 608-268-1817 WHA Transition

16. Action Items 1.Build your improvement team 2.Make sure that all webinars are on your calendars 3.Review Top 10 list and Gap Analysis 4.Don’t get bogged down by EHR concerns… 5.Come back in May The Next 30 Days

17. Next webinar: Wednesday, May 25, 2016 12:00 – 1:00 pm Questions?

18. Please complete the brief post-webinar survey We value your feedback and will follow- up with you if requested Thank you! Thomas Kaster, tkaster@wha.org