The American Society of Health-System Pharmacists (ASHP) Research and Education Foundation announced OhioHealth, Inc., as the recipient of the first annual Award for Excellence in Medication-Use Safety for 2004. The two finalists were Children’s Medical Center in Dayton, Ohio, and Fairview Health Services in Minneapolis, Minneapolis.
“This award recognizes the achievements of practitioners who have measurably improved the safety of patients’ medication use through major practice interventions or continuous quality-improvement initiatives,” said Stephen J. Allen, Executive Vice President and Chief Executive Officer of the ASHP Foundation. “We intend to communicate their accomplishments widely to expand the knowledge of medication-use best practices, pharmacist leadership and enhanced teamwork among health professionals.”
The three sites were chosen by an interdisciplinary panel of judges, who evaluated 42 applications. Finalists were chosen based on criteria focusing on achievements in medication-use system initative/scope, planning and implementation, measurable outcomes and impact and innovation and applicability. Judges visited each finalist site before selecting a recipient.
The recipients were also highlighted in an article that appeared in Drug Topics in January 2005. Click here to see the article.
The recipient and finalists were announced December 5, 2004, at an invitation-only luncheon held during the 2004 ASHP Midyear Clinical Meeting. OhioHealth received a $50,000 award, while Children’s Medical Center and Fairview Health Services each received a $10,000 award.
2004 Awardee — OhioHealth in Columbus, OH
The 2004 recipient, OhioHealth, located in Columbus, was chosen for its superb leadership by pharmacists of a very successful initiative that made tangible improvements. OhioHealth incorporated prevention of adverse drug events (ADEs) into its organizational quality initiative. Efforts included adoption of mechanisms to consistently identify ADEs, development of measures that could impact systematic change and providing a platform to share best practices across the system. Data for the 10 months following implementation of these changes indicate a 51% reduction in ADEs across the OhioHealth system. Other key outcomes include ongoing validation of a tool to classify the severity of reported ADEs and the development of a system-wide Medication Safety Coordinator. This site used extensive chart review using trigger identification of ADEs.
“OhioHealth’s mission is to ‘improve the health of those we serve,’ so we are pleased and honored to receive this prestigious award recognizing our focused efforts to make hospitals safer for our patients,” said Tom Sherrin, Director of Clinical Resource Management for OhioHealth. “Drug-related events are among the most common types of adverse events that occur in hospitals nationally. It is essential and appropriate that pharmacists, who are key players in health care, focus on improving medication-use safety. This award validates our ongoing efforts to decrease adverse drug events and will help fund the next steps in our plan to protect patients through every step of the healthcare continuum.”
OhioHealth is a health system composed of 7 member and 6 affiliate hospitals that have over 70,000 non-obstetrical admissions annually. This system contains both teaching and non-teaching hospitals and serves urban and rural populations. In 2001, OhioHealth incorporated prevention of adverse drug events (ADE) into its organizational quality initiative. This included adoption of mechanisms to consistently identify ADEs, development of measures that could impact systematic change and provision of a platform to share best practices across the system.
A multidisciplinary Patient Safety Steering Committee determined that implementation of computerized triggers along with enhanced voluntary reporting were key to identifying ADEs. Following pilot studies, there was a decision to focus on ADEs related to three high-risk and frequently used medication groups – anticoagulants, sedatives including benzodiazepines and opioids, and insulin products. Each hospital in the system was charged with developing an action plan to decrease ADEs related to at least one of these medication groups. Key outcomes of this heightened focus on medication safety include:
• Implementation of an inpatient anticoagulation dosing and monitoring service
• Development of a policy to increase appropriate use of Patient Controlled Analgesia PCA and development of standardized PCA orders
• Elimination of opioid range orders
• Development of standardized insulin order sheets and treatment algorithms
• Ongoing validation of a tool to classify the severity of the reported ADE
• Inclusion of ADEs as a quality metric in a systemwide report card used by OhioHealth
• Development of a systemwide Medication Safety Coordinator
• Creation of a Pharmacy Practice and Medication Safety Residency
Data for the 10 months following implementation of these changes indicate a 51% reduction in errors across the OhioHealth system. As a result of these initiatives, there has been a movement toward viewing ADEs as system failures rather than individual failures. Next steps include expansion of these patient safety initiatives to the ambulatory arena including urgent care centers, rehabilitation centers and physician practices.
Lori Bryant, R.N.
Kathryn Crea, Pharm.D.
Jonathan Edmonds, R.Ph.
Linda Gaskell, R.N.
Rebecca Hall, R.N.
Margaret Huwer, Pharm.D.
Charles McCluskey, Pharm.D.
Roger McKinstry, R.Ph.
Neil Messerly, R.Ph.
C. David Moorehead, M.D.
Rory Phillips, R.Ph.
Tom Sherrin, R.Ph., M.S.
Carol Solie, M.D.
Richard Snow, D.O., M.P.H.
Rod Wirsching, Pharm.D.
Harry Woolhiser, R.Ph.
In addition to being highlighted as the 2004 winner, members of OhioHealth's Patient Safety Council presented their work at an educational session at the ASHP Summer Meeting entitled "Reducing ADE's in Your Institution: Strategies and Practical Tools for the Real World: A report from the 2004 winner of the Award for Excellence in Medication-Use Safety." This session focused on reviewing the accomplishments of OhioHealth that won them the 2004 Award for Excellence in Medication-Use Safety. Speakers provided examples of forms, tools and data collection methods giving participants practical ways to apply these practices in their own institution. Also, the program reviewed subjects such as the importance of pilot studies, the trigger tool they modified and used based on literature review, severity ranking of ADE's, standardized forms across the system, accountability including the use of a scorecard, and return on investment for the resources dedicated to the initiative. Many of the standardized data collection forms and tools developed by OhioHealth were available on the CD-Rom of Supplemental Educational Resources.
2004 Finalist — Children’s Medical Center in Dayton, Ohio
Children’s Medical Center made improving the medication-use process one of its strategic goals and developed a multidisciplinary Medication Process Action Team to analyze and affect change in the organization’s medication-use processes over a 4-year timeframe. Changes made included changing the process for obtaining patient weights in the emergency department, developing a consistent medication labeling system, and enhancing the use of medication infusion devices. Children’s also required all staff to complete computer-based safety education modules and enhanced patient and caregiver education related to medication use. This site based their actions on extensive analysis of results from using the ISMP Self-Assessment Survey Tool.
Following the release of the 1999 Institute of Medicine Report, To Err Is Human: Building a Safer Health System, Children’s Medical Center in Dayton, Ohio, recognized an institutional imperative for safety-related changes and improvements. This movement to change the culture of safety was driven by staff recognition of the need, enhanced awareness by the Board of Trustees, and increased patient and caregiver participation in treatment decisions. Following completion of an Institute for Safe Medication Practices survey in 2000, Children’s Medical Center developed a multidisciplinary Medication Process Action Team whose mission was supported through a Board of Trustees resolution. This 14-member multidisciplinary team consists of educators, health-system executives, nurses, pharmacists and physicians.
In 2001, improving the medication-use process became one of Children’s strategic goals. Over a 4-year period, the multidisciplinary team met bimonthly to analyze and affect change in the organization’s medication-use processes. Following completion of a series of Failure Mode Effect and Criticality Analyses, organization-wide changes included:
• Changing the process for obtaining patient weights in the emergency department
• Development of a consistent medication labeling system
• Enhancement of medication infusion devices
• Improved processes for managing Total Parenteral Nutrition
• Purchase and installation of standardized reference materials
• Reconfiguration of the organization’s incident reporting system
• Standardization of the formulary addition process
• Standardization of medication concentrations
A key component of the successes at Children’s was a commitment to staff education related to these safety improvements. All hospital staff completed computer-based safety education modules and additional training was required of clinical staff. There has also been an emphasis on enhancing patient and caregiver education related to medication use. Along with the numerous accomplishments listed above, a significant culture change has occurred at Children’s Hospital of Dayton; there is now widespread organizational ownership for assuring safe medication use.
Cindy Brown, R.N., M.S.N
Lori Chaney, R.N.
Hila Collins, R.N., M.S.
Connie Doty, R.N., M.S.
Carol Green, R.N.
Daniel Preud’Homme, M.D.
Gregory Huff, R.Ph.
Jennifer Isham, R.N.
Jodi Mullen, R.N., M.S.
Thomas, Murphy, M.D., M.P.H.
Stacy Roehrs, Pharm.D.
Nancy Severt, R.Ph.
Hillary Stamp, M.D.
Carol Wise, R.N., M.S.
2004 Finalist — Fairview Health Services in Minneapolis, Minnesota
Fairview Health Services set a goal to reduce ADEs by 90% over a 5-year period. To accomplish this, Fairview established an ADE trigger tool at all sites, reduced serious over-sedation from 1 per 2,000 cases to 1 per 11,000 cases, and involved pharmacy technicians in the medication history process which resulted in an 82% reduction in incomplete histories. Fairview also standardized order and checking of high-risk medications.
Fairview Health Services is an integrated health system composed of seven hospitals, clinics, retail pharmacies, long-term care facilities as well as a home care and hospice agency. Annual admissions exceed 75,000, and over 11,000 people are employed by Fairview. Four formal committees, with multidisciplinary membership, oversee various aspects of the medication-use process. Fairview has set a goal to reduce adverse drug events (ADEs) by 90% over a 5-year period. Fairview’s commitment to significant ADE reduction has resulted in:
• Establishment of an ADE trigger tool at all sites.
• Reduction of serious over-sedation from 1 per 2,000 cases to 1 per 11,000 cases.
• A 76% reduction in supratherapeutic INRs at 2 clinics following implementation of pharmacist-directed anticoagulation services.
• Involvement of pharmacy technicians in the medication history process, resulting in an 82% reduction in incomplete histories.
• Standardization of orders and checking of high-hazard medications.
• Implementation of 86 best practices across the Fairview system.
Along with these tangible examples of Fairview’s medication safety initiatives, they have adopted an understanding that practice change requires a change in critical thinking involving enhanced communications, mentoring and oversight. They also recognize that to achieve excellence, an organization must identify and correct all sources of failure regardless of the rarity of the event.
Robert Beacher, R.Ph.
Barry Bershow, M.D.
Mary Beshara, R.N., M.S.N.
James Bishop, M.D.
Marti Bollman, R.N.
James Breitenbucher, M.D.
Mary Jo Brueggeman, R.N.
Kate Cummings, R.N.
Richard Dinter, M.D.
Craig Else, Pharm.D.
Kelly Ferkul, Pharm.D.
Michael Frakes, Pharm.D.
Lisa Ganske, R.Ph.
Ron Greenberg, Pharm.D.
Joseph Gutenkauf, M.D.
Caren Jacobs, Pharm.D.
Scott Knoer, MS, Pharm.D.
Beth Krehbiel, R.N.
Lisa Lohr, Pharm.D.
Robin Madsen, R.N., M.S.N.
Steven Meisel, Pharm. D.
Mary Meisel, R.N., M.S.N.
Ryan Michels, Pharm.D.
David Miller, R.Ph.
Mark Nelson, R.Ph.
Alison H. Page, R.N., M.H.A.
Jamie Peters, M.D.
Pamela Phelps, Pharm.D.
Steve Ritter, MBA, R.Ph.
Darla Roggow, R.N., M.S.N.
David Swinarski, R.Ph.
Bruce Thompson, R.Ph.
Karen Tomes, R.N.
Neal Walker, R.Ph.
Carl Woetzel, Pharm.D.