Jason Trahan, Pharm.D . Director of Pharmacy – Medication Safety, Baylor Scott & White

1. Intermountain-led CMS Hospital Engagement Network Adverse Drug Event PreventionSeptember 23, 2014 Affinity Call Jason Trahan, Pharm.D. Director of Pharmacy – Medication Safety, Baylor Scott & White Lucy Savitz, Ph.D., M.B.A. HEN Director

2. Outline for Discussion • Review of the HEN ADE work • “Just-one-thing” Recommendations • High performers • Pharmacy Patient Safety at Baylor Scott & White • Q & A/ Discussion

3. Overall Progress Through Q1 2014

4. Intermountain HEN 2012-Q1 2014 ADE w/ Harm

5. Intermountain HEN 2012-Q1 2014 ADE w/ Harm

6. Intermountain HEN 2012-Q1 2014 ADE per 1000 Patient-Days

7. Intermountain HEN 2012-Q1 2014 ADE per 1000 Patient-Days

8. Intermountain HEN 2012-Q1 2014 PSI 12 Post Operative PE or DVT

9. Intermountain HEN 2012-Q1 2014 PSI 12 Post Operative PE or DVT

10. Intermountain HEN 2012-Q1 2014 • ADE Due to Opioids • Controlled Postoperative Serum Glucose • Excessive Anticoagulation with Warfarin • Low Reporting

11. Just One Thing MatrixRecommendations

12. High Performing Hospital Highlight…ADE w/ Harm

13. High Performing Hospital Highlight… ADE per 1000 Patient-Days

14. High Performing Hospital Highlight… PSI 12 Post Operative PE or DVT

15. Pharmacy Patient Safety September 23, 2014 Jason Trahan, Pharm.D. Director of Pharmacy – Medication Safety

16. Presentation Outline • Focus on Pharmacist involvement in two of ten patient safety areas: • Adverse Drug Events • Use of Data • Vancomycin • Response to current literature • Fentanyl Patches • Haloperidol Intravenous Use • Injuries from Falls • Response to current literature • Zolpidem

17. Adverse Drug Events • Changes evaluation from facility specific to enterprise-wide in 2013. • Increased usefulness of data and trending • Reported Quarterly at enterprise and facility meetings.

19. Vancomycin • Facility specific practices collected / analyzed. • Pharmacy and Therapeutics Committee approval to standardize infusion times to 10 mg/min. • Implementation in Electronic Health Record, IV Pump Library, Order Sets, etc. • Fully implemented first quarter 2014.

20. Proactive Use of Data • Facility specific practices collected / analyzed. • Pharmacy and Therapeutics Committee approval to standardize infusion times to 10 mg/min. • Implementation in Electronic Health Record, IV Pump Library, Order Sets, etc. • Fully implemented first quarter 2014.

21. Response to Current LiteratureFentanyl Patch Disposal • FDA Alerts: • April 2012 (Accidental Exposure) • September 2013 (Patch Writing Color Change) • Institute for Safe Medication Practices: • August 2013 (“Bystander Apathy – We ALL have a role in prevention”) • Action Plan • Outpatient • Inpatient

22. Action PlanFentanyl Patch Disposal • Outpatient Baylor Health Enterprises Pharmacies • Pharmacists Utilizing standardized teaching tool emphasizing disposal • Tool can be found: www.ismp.org/AHRQ/default.asp • Inpatient Care • Nursing Education for Fentanyl, Fold, and Flush • Consistent message across continuum of care

23. http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/UCM337803.pdfhttp://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/UCM337803.pdf

24. Haloperidol Use • Society of Critical Care Medicine • Revised Guidelines Published January 2013 • Prior to update, the use of haloperidol for the treatment of delirium was in the guidelines (Level C Recommendation) • “There is no published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients”

25. Haloperidol Use • Action Items: • Removed from Enterprise ICU Delirium Order Sets. • Recommended that patients receiving via the intravenous route of administration considered for telemetry monitoring.

26. Zolpidem • Journal of Hospital Medicine 2013;8:1-6 “Zolpidem is Independently Associated with Increased Risk of Inpatient Falls” – Published January 2013. • FDA Drug Safety Communication – January 2013 • FDA Requires lower recommended doses…

27. Zolpidem • Action Plan: • Electronic Health Record Changes • Revise order sets to remove pre-selection of prn insomnia medication. • Dose revision to remove 10 mg ordering option • Only 5 mg on order sets • Removal of 10 mg order sentence for quick ordering

29. AHRQ eLearning Lesson on Preventing ADE “Preventing ADE: Individualizing Glycemic Targets Using Health Literacy” An interactive eLearning course offered by the Office of Disease Prevention and Health Promotion, teaches providers how to: • Apply health literacy strategies to provide personalized care for patients with diabetes, and to help them understand and act on information to prevent hypoglycemia • Apply current, evidence-based guidelines for individualizing glycemic target goals • Adopt the teach back method and shared decision-making in the health care setting Continuing education (CME, CNE, CEU and CPE) is available Visit http://health.gov/hai/training.asp#preventing_adesto participate