Adopting Real-Time Surveillance Dashboards as a Component of an Enterprisewide Medication Safety Strategy

doi:10.1016/S1553-7250(11)37041-9

The Joint Commission Journal on Quality and Patient Safety

Volume 37, Issue 7, July 2011, Pages 326-332, AP1-AP4

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https://doi.org/10.1016/S1553-7250(11)37041-9 Get rights and content

Article-at-a-Glance

Background

High-alert medications are frequently responsible for adverse drug events and present significant hazards to inpatients, despite technical improvements in the way they are ordered, dispensed, and administered.

Methods

A real-time surveillance application was designed and implemented to enable pharmacy review of high-alert medication orders to complement existing computerized provider order entry and integrated clinical decision support systems in a tertiary care hospital. The surveillance tool integrated real-time data from multiple clinical systems and applied logical criteria to highlight potentially high-risk scenarios. Use of the surveillance system for adult inpatients was analyzed for warfarin, heparin and enoxaparin, and aminoglycoside antibiotics.

Results

Among 28,929 hospitalizations during the study period, patients eligible to appear on a dashboard included 2,224 exposed to warfarin, 8,383 to heparin or enoxaparin, and 893 to aminoglycosides. Clinical pharmacists reviewed the warfarin and aminoglycoside dashboards during 100% of the days in the study period—and the heparin/enoxaparin dashboard during 71% of the days. Displayed alert conditions ranged from common events, such as 55% of patients receiving aminoglycosides were missing a baseline creatinine, to rare events, such as 0.1% of patients exposed to heparin were given a bolus greater than 10,000 units. On the basis of interpharmacist communication and electronic medical record notes recorded within the dashboards, interventions to prevent further patient harm were frequent.

Conclusions

Even in an environment with sophisticated computerized provider order entry and clinical decision support systems, real-time pharmacy surveillance of high-alert medications provides an important platform for intercepting medication errors and optimizing therapy.

Section snippets

Surveillance Tool Design

The surveillance tool is a Web application that organizes patient data onto dashboards on the basis of provider-entered orders for high-alert medications. Messages from clinical and administrative systems are parsed and stored in a relational database. Scheduled tasks analyze new data for patient eligibility, calculate alerts, and compile the appropriate patient characteristics for the dashboards. All user activity is logged into the database.

Authenticated users initially see a summary page

Patient Population

There were 28,929 adult inpatient admission and observation encounters during the 183-day study period, with an average daily census of 576 cases. The proportion of cases with a positive alert relative to the number of cases exposed to the drug are shown in Table 2 (page 329). The most common alerts occurred on the aminoglycoside dashboard and concerned missing or delayed monitoring of serum creatinine.

Dashboard Coverage and Utilization

Drug exposure, coverage, and utilization for the three dashboards are shown in Table 3 (page

Discussion

The real-time surveillance tool successfully synthesizes data in real-time, prioritizes patients on the basis of predefined clinical data rules, and facilitates pharmacist-to-pharmacist and pharmacist-to-clinical team communication. In a health care system where each of the dashboard medications already relied on advanced initial dosing decision support during the time of this study, our initial experience with implementation shows a high rate of use and need, with frequent monitoring (100%)

Future Directions

Although current reported research has described ADE surveillance in adults, there are implications for multiple potential applications and clinical audiences. For example, pediatric pharmacists are currently being engaged at VUMC to improve the use of anticoagulants. Infection control teams could use a dashboard that takes advantage of newly available structured microbiology reports to help meet Joint Commission National Patient Safety Goals regarding the prevention of health care–associated

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Adopting Real-Time Surveillance Dashboards as a Component of an Enterprisewide Medication Safety Strategy

Article-at-a-Glance

Background

Methods

Results

Conclusions

Section snippets

Surveillance Tool Design

Patient Population

Dashboard Coverage and Utilization

Discussion

Future Directions

J Am Med Inform Assoc

J Am Med Inform Assoc

J Am Med Inform Assoc

Am J Kidney Dis

J Am Med Inform Assoc

The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II

N Engl J Med

Computerized surveillance of adverse drug events in hospital patients

JAMA

JAMA

Incidence of adverse drug events and potential adverse drug events: Implications for prevention

JAMA

The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Group

JAMA

To Err Is Human: Building a Safer Health Care System

Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients

Pediatrics