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Beyond ePrescribing. Factors Influencing Patient Safety in Medical Group Practices - September 26 th , 2007 AHRQ 2007: Improving Healthcare, Improving Live Larry Garber, M.D. – Medical Director for Informatics. Overview. Sources of Adverse Drug Events (ADE’s) in the ambulatory setting

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beyond eprescribing

Beyond ePrescribing

Factors Influencing Patient Safety in Medical Group Practices - September 26th, 2007

AHRQ 2007: Improving Healthcare, Improving Live

Larry Garber, M.D. – Medical Director for Informatics

  • Sources of Adverse Drug Events (ADE’s) in the ambulatory setting
  • Reducing anticoagulant-related ADE’s
  • Future plans and barriers to reducing ADE’s

Sources of ADE Information

Field, TS et al. JAMIA 2004;52:1349-1354.

ade rates in the ambulatory setting
ADE Rates in the Ambulatory Setting
  • ADEs:50 per 1000 person-years
  • Preventable ADEs: 14 per 1000 person-years (28%)
  • Extrapolated to total Medicare 65+:1,446,949 ADEs per year438,046 preventable ADEs/year
  • This is likely to be an underestimate

Gurwitz JH et al JAMA 2003;289:1107-1116

financial cost of ade s
Financial Cost of ADE’s

Field TS, et al Medical Care 2005;43:1171-6

financial cost of ade s1
Financial Cost of ADE’s
  • Increase in costs after an ADE: $1310Increase after a preventable ADE: $1983
  • Extrapolated to 1000 adults age 65+Costs per year to treat preventable ADEs:$27,365
severity preventability
Severity & Preventability

Of less serious events

Of fatal & life-threatening






fallon approach to preventing ade s
Fallon Approach to Preventing ADE’s
  • First target the Fatal & Life-Threatening preventable ADE’s
    • Warfarin
  • Then do a system-wide solution for the others
preventing warfarin ade s
Preventing Warfarin ADE’s
  • Ordering/Prescribing
    • ePrescribing with drug interaction checking
    • Simplified referrals to Anticoagulation Clinic
  • Monitoring
    • Converted Anticoagulation Clinic to Epic’s EHR
    • Simplified tracking of lab no-shows

Full dosing information is entered and available to be seen by all physicians and staff

Date of next INR is entered to trigger tickler system


INR Reminder automatically appears in the Anticoagulation Clinic In-basket on the patient’s due date, and doesn’t disappear until the due date is changed

preventing other ade s
Preventing Other ADE’s
  • Use probabilistic risk assessment to:
    • characterize systemic and behavioral elements that increase of ADE’s during ordering/monitoring
    • identify potentially high-yield and likely-to-be-successful interventions
  • Estimate likelihood that interventions at any given step would be successful in reducing errors at that step
  • Select interventions for implementation

Field TS et al AHRQ Grant # 1P20HS017109-01

barriers to preventing ade s
Barriers to preventing ADE’s
  • Most organizations don’t have EHR’s
  • ePrescribing doesn’t solve the monitoring problem
  • Many EHR’s don’t currently have the functionality to provide alerts for missing events without being in the context of a patient encounter
  • MD compliance
  • Time and money required to build interventions
  • ADEs are common and often preventable
  • Types of errors suggest focus on prescribing and monitoring
    • Provision of information to physicians and assistants at right time, right place…
    • Use of automated tickler systems
  • Costs are high and savings from preventing ADEs could partially offset costs of interventions

Larry Garber, M.D.

Special thanks to Terry Field, PhD and Jerry Gurwitz, M.D. for their assistance on this presentation and never-ending work to study and prevent ADE’s