let's rethink allergies and adverse drug reactions

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Click to edit Master title styleLets rethink Allergies and Adverse Drug ReactionsRob Ticehurst, Principal Pharmacist, Auckland DHB

Pharmacy

Supporting the patient medication pathway to deliver the best outcomes

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PharmacySupporting the patient medication pathway to deliver the best outcomes

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A Tragic AccidentDevastating for all involvedFamilyStaffWe owe it to Eunices family to learn from this and change the system it mustnt happen again

PharmacySupporting the patient medication pathway to deliver the best outcomesNo-one meant to do Eunice harm. Despite warnings being in place, processes still fell over and meant that Eunice was administered an antibiotic to which she had a known severe allergy and that contributed to her death.Unfortunately this is not an un-common event. Thankfully few have such a severe outcome but the potential for significant harm remains. These incidents are entirely preventable.3

NHIMedical Warning System

PharmacySupporting the patient medication pathway to deliver the best outcomesEunice wore a medic alert bracelet warning of her allergy status. Her allergy had been notified to the Centre for Adverse Reaction Monitoring and as in the National Medical Warning system linked to her NHI.There was clear documentation on her paper medication chart, (Slide, slide) however events still conspired to enable Eunice to be given the medicine.This is illustrative of the difficulty of putting hard stops to prevent this sort of incident occurring with a mix of paper and electronic systems.4

PharmacySupporting the patient medication pathway to deliver the best outcomesEunice wore a medic alert bracelet warning of her allergy status. Her allergy had been notified to the Centre for Adverse Reaction Monitoring and there was clear documentation on her paper medication chart, however events still conspired to enable Eunice to be given the medicine.This is illustrative of the difficulty of putting hard stops to prevent this sort of incident occurring with a mix of paper and electronic systems.

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TRIMETHOPRIMALLERGY

PharmacySupporting the patient medication pathway to deliver the best outcomesEunice wore a medic alert bracelet warning of her allergy status. Her allergy had been notified to the Centre for Adverse Reaction Monitoring and there was clear documentation on her paper medication chart, however events still conspired to enable Eunice to be given the medicine.This is illustrative of the difficulty of putting hard stops to prevent this sort of incident occurring with a mix of paper and electronic systems.

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ePrescribing & AdministrationImplementation due in all DHBs by end of 2016SouthernTaranakiWaitemataCanterburyIt reduces the risk of errors, and alerts doctors to potential issues such as under- or over-prescribing, medicines that are contra-indicated and allergies.NHIT Plan Update

PharmacySupporting the patient medication pathway to deliver the best outcomesThe latest update of the National Health IT Plan indicates that all DHBs should have electronic prescribing and administration in place by the end of 2016.4 DHBs are already well into their implementation. Auckland DHB is nextThe same document states that ePA will reduce the risk of errors, and alert doctors to potential issues such as under- or over-prescribing, and the administration of medicines that are contra-indicated or that a patient has known allergies to.7

alerts doctors to potential issues such as under- or over-prescribing, medicines that are contra-indicated and allergies

PharmacySupporting the patient medication pathway to deliver the best outcomesLets take another look at that - alerting users of the system to the presence of allergies - fantastic.

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alerts doctors to potential issues such as under- or over-prescribing, medicines that are contra-indicated and allergies


PharmacySupporting the patient medication pathway to deliver the best outcomesSo surely when we add in the detail held within existing electronic systems such as CARM and Medic Alert then tragic accidents like Eunices will never happen again. 9

Problem solved?No

PharmacySupporting the patient medication pathway to deliver the best outcomesProblem solved? Unfortunately not.10

Why not?MWS medication field is free text

ePA requires the manual entry of a patients allergy status

PharmacySupporting the patient medication pathway to deliver the best outcomesThe medication field in the Medical Warning System is a freetext field. In one DHBs record system there are over 15 terms that have been used to describe a single medicine!Its very difficult to run Clinical Decision Support against free text and therefore we require our clinicians to enter the data manually to enable the decision support to work.

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Done that surely problem solved?Partially

If a patient moves to a different DHB that allergy needs to be entered in the ePA system all over again

PharmacySupporting the patient medication pathway to deliver the best outcomesSo once the allergy status has been manually entered in the system it works beautifully. No argument there! However, our patients do move between DHBs particularly when they are very sick and therefore at their most vulnerable. This is particularly true in the Auckland Region. There is currently no ability to transfer data between hospitals running the same ePA system nor is there any indication as to when this will be possible.12

Are you serious?Houston, we have a problem.Thankfully we arent planning a trip to the moon.

We need to collect, transfer and utilise around a dozen fields of information.

PharmacySupporting the patient medication pathway to deliver the best outcomesUnfortunately yes. We do indeed have a problem. However, the reality is that we just need a system that will facilitate the collection, transfer and utilisation of a very small amount of data.13

The building blocks are there

PharmacySupporting the patient medication pathway to deliver the best outcomesAlmost 40 years on from the introduction of the Medical Warning System we have some key enablers in place to help us to make a difference14



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PharmacySupporting the patient medication pathway to deliver the best outcomesFast Healthcare Interoperability ResourcesEmerging standards to help us transfer this information around.20



PharmacySupporting the patient medication pathway to deliver the best outcomesAnd we have some very smart people to help us join the dots21

What next?No more excusesWe owe it to Eunice and others before herWithin this room we have the skills, knowledge and power to address this issueLearn from others this is not just an NZ issueLets collaborate and pilot something in the Auckland region that is scalable for National useShowcase at the IHTSDO 2016 NZ meeting

PharmacySupporting the patient medication pathway to deliver the best outcomesLets break down the barriers.Lets ensure we learn from others who are on this same journey Spain, Denmark and other IHTSDO members 22

Thank youNorthern Region Allergy & ADR groupNHITB All of you

PharmacySupporting the patient medication pathway to deliver the best outcomesNHITB for accepting the challengeYOU for ensuring this happens23