1 / 18

Delivering a Healthy WA

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. Armadale Health Service (AHS). Overview:. Med Rec (MR) in AHS

kana
Download Presentation

Delivering a Healthy WA

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. Armadale Health Service(AHS)

  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

  5. Common Drug Errors in MR Exclude ADR documentation

  6. Aims and Method to Quantify MR: Aims: 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

  7. Definition of ADEs: (Adverse Drug Events ΞActual 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 ΞAdverse Drug Events ΞActual Drug Errors

  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

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

  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

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

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

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

  15. Lesson learnt:

  16. Lesson learnt: •  KPI1 and KPI2 (≠ 0 ADE): • 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

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

More Related