1. Using Key Performance Indicators (KPIs) from Medication Reconciliation (MR) to Quantify and Prevent Future Adverse Drug Events (ADEs) Stephen Lim, TT Chih, E Fong Pharmacy, Armadale Health Service
Delivering a Healthy WA

2. Armadale Health Service (AHS)2

3. Overview: Med Rec (MR) in AHS Aim and Method to quantify MR
Definition of:
Adverse Drug Events (ADEs)
Key Performance Indicators (KPIs)
Achievements of KPIs
Prevention of future ADEs
Lesson learnt

4. Med Rec (MR) in AHS Since 2007 SQuIRe funded project
Marketed as Med Matching (M+M) program
70-90% M+M for all admitted patients
Sustainable program
Common errors in MR 4

5. Common Drug Errors in MR
Exclude ADR documentation 5

6. Aims and Method to Quantify MR:
To quantify success or failure in MR
Use KPIs to  or prevent ADEs
Method:
Daily data collection from MR activities
Analyse data monthly using 4 KPIs 6

7. Definition of ADEs: (Adverse Drug Events Ξ Actual Drug Errors)
Potential Drug Errors:
MR < End of Next Calendar Day (ENCD)
near misses (rectified before drug admin)
Not counted as ADEs
Actual Drug Errors:
MR > ENCD
Counted as ADEs due to:
Med not admin (Rx omission)
Wrong drug/dose admin (incorrect Rx)

8. Case study (patient AO, 70y, ♀) ADE Ξ Adverse Drug Events Ξ Actual Drug Errors
NIMC
NIMC dose
BPMH (Best Possible Med History)
Dose admin?
Aspirin (commission error)
100mg mane
Ceased months ago
1 dose (ADE √)
Mirtazapine (commission error)
15mg nocte
-ditto-
Tamoxifen (commission error)
20mg nocte
Calcium (omitted Vit D)
1 d
Ca plus Vit D
1 dose omitted (ADE √)
Frusemide
40mg m
20mg mane
Intentional dose change (ADE X)
Olmesartan (omitted HCT)
40mg mane
Olmesartan + HCT 40/12.5mg mane
Prochlorperazine
5mg mane
(wrong dose)
5mg tds
2 doses missed (ADE √)
Fosamax plus (commission error)
1 weekly
Not admin (ADE X)

9. Definition of 4 KPIs: KPI1 = ADEs per 1000 doses administered
Number ADEs ÷ Number med doses admin (30 random patients/month) X 1000
KPI2 = ADEs per 100 med written (Rx)
Number ADEs ÷ total med written X 100
KPI3 = Pharmacy Interventions per 100 patients
Total pharmacist clinical interventions ÷ total MR patients X100
KPI4 = ADEs per 100 patients seen >ENCD
Number ADEs ÷ total MR patients X 100 9

10. ACHIEVEMENT : KPI1 ADEs per 1000 doses
Average 4.7 ADEs per 1000 doses
= 1 ADE per 200 doses
Trendline
ADEs 10

11. ACHIEVEMENT: KPI2 ADEs per 100 med Rx
17 drug errors for every 100 meds written
13 ADEs prevented due to MR
4 ADEs for every 100 meds written
Trendline
ADEs 11

12. ACHIEVEMENT: KPI3 Pharmacy Interventions per 100 patients
122 clinical interventions
per 100 patients
64 MR activities
per 100 patients
Trendline
 MR 12

13. KPI4: ADEs per 100 admissions (Do Nothing KPI!)
83 ADEs per 100 patients
(MR > ENCD)
Flat trendline:
Error when no MR 13

14. Prevent Future ADEs:
Goal:
 ADEs to  harm:
KPI1
 KPI2
↑ KPI3
KPI4

15. Lesson learnt:

16. Lesson learnt:  KPI1 and KPI2 (≠ 0 ADE): ↑ KPI3:
timely Med Rec (within ENCD)
involve all clinicians in MR
↑ KPI3:
50% clinical pharmacist workload is MR related
KPI4 remains constant if no MR
0.8 ADE per patient

17. Assigning Risk Rating to ADEs
ADEs risk rating: from 0-3
0 = near miss
1 = low (no harm has occurred)
2 = moderate (extra monitoring eg. digoxin level had to be ordered, extra obs (BP/BSL) needed, Dr reviewed patient, no extra treatment required).
3 = severe (required extra treatment, t/f to another hospital/unit, ↑ LOS, readmission)

18. Conclusion: To  ADEs: Timely Med Rec within ENCD
Involve all clinicians in MR