1. The Health Roundtable Using IHI Global Trigger Tool to monitor Adverse Drug Events Presenter: Helen Ward The Prince Charles Hospital _ Qld Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1 4-4d_HRT1215-Session_WARD_TPCH_QLD

2. The Health Roundtable KEY PROBLEM  Voluntary reporting identifies only 10 to 20 % of errors  over 95% medication errors cause no harm to patients.  Concern that some classes of adverse events are not being reported 2

3. The Health Roundtable AIM OF THIS INNOVATION  To identify events that cause patient harm in order to:  quantify the degree and severity of harm  provide objective measure of adverse drug events (ADE) to monitor effectiveness of current medication safety systems 3

4. The Health Roundtable AUSTRALASIAN VERSION of IHI GTT  Developed in conjunction with IHI and HRT  16 hospitals trained by IHI over 5 months from June 2010  Patient harm defined as: Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death. The IHI GTT counts only adverse events which cause harm to the patient whether or not it is the result of an error. 4

5. The Health Roundtable KEY CHANGES IMPLEMENTED  10 randomly selected medical records reviewed fortnightly  Primary reviewers (4 nurses, 1 pharmacist, 1 HIM)  2 reviewers independently use “triggers”, coding, incident reports  Meet together to agree on AE (Harm)  Primary reviewers meet with medical reviewer (physician, EDMS)  Agree on Harm and Category  Seek extra data if unclear  Second monthly meeting of all reviewers to discuss all AE and agree on inclusions/exclusions 5

6. Frequency for Period: Cycle 1 to 48 (April 2010 to March 2012) Adverse Events Severity Harm Category (16% Present On Admission ) EFGHI Medication/IV Fluids (28%)25167020 Patient Care (4%)25241000 Hospital Acquired Infection (7%)1366010 Surgery or Other Procedure (19%)361714041 Other101000 Total1006329071 TPCH Adverse Event and Severity by Harm Category (480 cases) Severity levels: E: Temporary harm requiring intervention F Temporary harm requiring initial/prolonged hospitalisation G: Permanent harm H: Intervention required to sustain life I: Death 6

7. The Health Roundtable Data base Oct 10 Apr 11 Apr 10Oct 10Apr 11Oct 11 31.9 40.1 7

8. The Health Roundtable Comparison with other IHI GTT sites AE /1000 pt days% ADE TPCH (24 mo)36.4 (16% POA) 25 (28% POA) N Carolina56.528 New Zealand46.950 POA : present on admission 8

9. The Health Roundtable ADVERSE DRUG EVENTS - Present on Admission  E - Hypotension due to GTN  E - Cough secondary to rimapril  F - epistaxis from OD of Warfarin  F - seizures after rapid withdrawal of meds  F - ADR secondary to Amoxil prescribed by GP  F - postural hypotension secondary to diuretics  H - neutropenic sepsis secondary to chemo 9

10. ADVERSE DRUG EVENTS – Drug Side Effects  E - hypoglaecemia requiring intervention  E - 2 x hypoglycaemic episodes  E - prolonged post op nausea, did not increase LOS  E - nausea & vomiting post op requiring multiple anti emetics  E - prolonged nausea post op  E - fall due to drowsiness with Capanol  E - hallucinations secondary to oxycontin  E - constipation secondary to opiates  E - oversedation with opiates  E - bleeding secondary to aspirin & clopidogril  E - bradycardia due to Metoprolol  E - deterioration in renal function secondary to hyoptension / NSAID use  F - kidney injury ? Secondary to fluclox  E - thrombophlebitis due to fluclox 10

11. The Health Roundtable ADVERSE DRUG EVENTS – Allergies and Other  E - morphine allergy previously unknown – rash  H - anaphylaxis due to adenosine (not previously known allergy)  F - inadequate K+ replacement with IV frusemide --> cramps.  F - OD in ED of own meds 11

12. The Health Roundtable OUTCOMES SO FAR  Validated effectiveness of long standing medication safety systems  ADE reviewed by Medication Safety Committee  2 years data collection completed  No trends requiring further investigation  Insufficient numbers to monitor an intervention  ? useful to monitor the effect of changes in funding 12

13. The Health Roundtable LESSONS LEARNED  Decisions on priority by Executive/Board  Time allocation  Data presentation/KPI  Definitions and local “rules” essential  Database – use an existing one  Sustainability  Training additional staff  Funding – don’t start without it! 13