1. North Carolina/Virginia Hospital Engagement Network (NoCVA HEN) Reducing Adverse Drug Events

2. Partnership for Patients: Medication Safety Overview NoCVA Hospital Engagement Network Medication Safety Webinar April 16, 2013 Brian J. Isetts, RPh, PhD, BCPS

3. NoCVA Medication Safety Webinar PRESENTATION OVERVIEW Partnership for Patients Aims Magnitude of Drug-related Harms Urgent National Call to Action Questions to run on: What is contributing to current results? What can you do in your hospital to accelerate improvement?

5. Reducing Adverse Drug Events Over one-third of Hospital Acquired Conditions are ADEs in the Partnership for Patients focus Most significant cause of injury/death in hospitals At least 1.5 million preventable ADEs each year Office of Inspector General - Report of Nov. 2010 NEJM (Budnitz) 11/24/2011 – High impact ADEs AHRQ Brief #109 – ADE in1.9M hosp stays (2008) Joint Commission Standard MM 07.01.03

6. Medication Safety Focus Focus on reducing high impact medication harms related to anticoagulants, hypoglycemic agents, and opioids Reduce drug-related readmissions to improve care transitions Work closely with medication advisory groups in the Hospital Engagement Networks (HENs)

7. An Urgent National Call to Action: Getting a Little Help from our Friends Inventory of federal resources – Sec. Sebelius Expectations of Partnership for Patients results Federal Interagency Response to ADEs External stakeholder engagement in our work Patient and family engagement in our work Partnership for Patients resources from the evaluation and NCD contractors ADE Road Map from the Minnesota HEN

8. A Glimpse of the HEN Response to the Medication Safety Challenge March 1, 2012 - there were 3 HENs and 200 hospitals engaged in medication safety April 2 nd Webinar framed the challenge and established a vision for our journey July 15 th the “gang of 7 HENs” took responsibility for reducing high-impact harms Jan. 9, 2013 - 3,084 hospitals in 24 HENs engaged in medication safety improvement; 1,493 committed to reporting; 211 sustaining ↓

10. Anticoagulation Management Service – Performance Data (Hosp. of Univ. of PA) Data Value Pre- AIM Team

11. Summary of Progress with Measurement Examples Everybody pulling in the same direction Roadmap of Medication Safety Best Practices % of Patients on Warfarin with INRs > 5 % of Blood Glucose readings below 50 mg/dl % of Patients on Opioids given Naloxone Help the HENs help hospitals Using run charts to assess care improvements in real time at the patient’s bedside

12. What more can be done? What is contributing to successful hospitals? * CEO/CMO leadership in hospitals to engage all health team members * Individual guidance for hospitals in the science of rapid cycle quality improvement What can you do to accelerate progress in your hospital?