Event Analysis

Lessons learnt from Medication Reconciliation activities using Event Analysis to improve medication safety

Evonne Fong, Dale Mitchell, Stephen Lim

Pharmacy Department

Background

Medication Reconciliation (MR) since 2007 at AHS

?? How and what to measure??

SQuIRe • Compliance with MR processes on admission, transfer and discharge• Varying results

• Admission: approximately 50% of patients with MR done within 24 hours

• Discharge: approximately 70% of patients with discharge reconciliation done

KPIsWhat we found:

• 17.2 medication errors per 100 medications a patient takes

• 58.4 drug errors per 100 high risk patients

Where to next?? … High 5s

AHS joined WHO’s High 5’s Project in 2009• Global patient safety collaboration • Australia’s project: Assuring Medication

Accuracy at Transition Points of Care

Benefits….• New measures

• High 5s MR 1-4• **Event Analysis**

New High 5’s measures

1. Percent of patients with meds reconciled within 24 hours of admission

2. Mean number of outstanding undocumented intentional medication discrepancies per patient

3. Mean number of outstanding UNINTENTIONAL medication discrepancies per patient

4. Percent of patients with at least ONE outstanding unintentional discrepancy

Event Analysis (EA)

Unprecedented opportunity to obtain and analyse findings from around the world regarding safety and effectiveness of SOP • Contributing factors

• Any specific system changes needed

Unique? Similar? Why?

Event Analysis (EA)

Includes:• Description of event• Analysis of cause and effect• Identification of contributing factors• Recommended improvements in

processes/systems• Documentation of findings and

recommendations

Example – Ian’s Story

Day 1: Admitted to ED on 22/5/2013 (Wednesday)

Admission reason: mechanical fall for investigation and

rehabilitation + ?UTI

PMH: HTN, Parkinson’s Disease, neuropathic pain, depression

Pt unable to give accurate medication history

Pt transferred to acute medical unit

MO writes up medications on chart

Patient’s mobility assessed on the day of admission by physio

Example – Ian’s Story

Day 2: Patient transferred to General Medical ward

• Physio notes state decreased mobility and increased tremor

Day 3: reviewed by Consultant and Medical Officer.

• Noted decreasing mobility and worsening of tremor

• MO calls pharmacy and requests review of medications

• Notes state:

• “review of medications, discuss with GP about meds, ?Neurologist

involved in patient care; ?Increase dose and add medications”

Ian’s Story

Day 3:

After phone call from MO, a pharmacist reviews patient.

Patient poor historian; pharmacist phones wife and uses Webster pack to

obtain BPMH

When comparing BPMH to med chart, multiple discrepancies identified:

• Omitted levodopa/carbidopa CR 200/50mg nocte

• Omitted mirtazapine 30mg nocte

• Omitted pregabalin 25mg nocte

• Omitted quetiapine 50mg nocte

• Omitted amlodipine 10mg nocte

• Incorrect timing for patients other Parkinson’s medication

MO informed correct meds and times charted 56 hours post admission

Mobility and condition improved; patient discharged

Event Analysis

Incident reported by pharmacist doing BPMH

Decision made to complete EA

Concise EA completed by team:

• Chief Pharmacist

• Clinical Pharmacist

• Medical Officer

• Safety and Quality Unit Project Officer

Event Analysis

Event Details• Patient details• Narrative of what happened• Medications involved

Classification of extent of harm to the patient

Event Analysis

Contributing Factors Education and Training

• MO unable to collect BPMH accurately despite having Webster Pack. Did not know how

to decipher medication details from Webster Pack

• Missed the 10pm “slot”

Staffing

• Patient initially admitted to AMU for 24 hrs before transfer to medical ward. AMU does

not have allocated clinical pharmacist Med Rec not completed within 24 hrs.

• Gen Med pharmacist on leave; another pharmacist went to see pt when requested by Dr

Patient

• Patient poor historian

Primary Contributing Factors Education and Training

Event Analysis

Measurable actions/changes for hospital

Conclusion

Event analysis beneficial as a “fact finding” tool • Used to seek and investigate patient safety

problems to identify if there are problems with the SOP and to identify cause and effect

• Multidisciplinary approach

• Less labour/resource intensive than RCA

• Measurable actions and changes to implement to improve patient safety