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System Changes, Patient-Centeredness Improve Medication Safety

Adverse drug events (ADE) make up about 32 percent of all hospital-associated harm events, making them a target for reduction nationwide. As a member of the erstwhile Essential Hospitals Engagement Network (EHEN), Truman Medical Centers — a Kansas City, Mo., level I trauma center with 41 percent of its discharges covered by Medicaid — began tracking the use of narcotic reversal agents to estimate incidence of narcotic overdose, and the percent of international normalized ratio (INR) labs with a result greater than five, which reflects bleeding risk and may predict anticoagulant-related ADEs.

In a 2013 Quarterly Action Agenda, the Institute for Safe Medication Practices noted that many patients are receiving too high a starting dose of narcotics. This promoted Truman to decrease its default hydromorphone starting doses from 1 mg, 2 mg, and 4 mg to 0.25 mg and 0.5 mg.

The hospital also decreased the number of 4 mg vials stocked on units to encourage clinicians to choose lower narcotic doses, keeping them in supply only on units like cancer units and units treating patients with sickle cell disease, where 4 mg doses might be warranted.

Concurrently, in 2012-2013, there was a national shortage of morphine supplies, causing the health system to switch its primary morphine vial size from 5 mg to 2 mg, which might have curbed accidental overdoses. Pharmacy leadership estimated these two changes might have helped them reduce use of narcotic reversal agents by 48 percent.

Truman also has an over-anticoagulation order set that guides decision-making with best practices, based on whether the patient has signs or symptoms of bleeding. Additionally, the hospital has a comprehensive program for educating patients on the anticoagulant warfarin. Pharmacists and pharmacy interns use a script and a checklist to educate patients and their primary caregivers on the medication, regardless of how long they have been taking it. Patients and caregivers are educated throughout the hospital stay, so they have the opportunity to ask follow-up questions, if necessary.

Although the percent of INR labs with a result greater than five has remained consistent at Truman since mid-2012, anecdotal evidence suggests that patients feel more informed and better understand the risks associated with taking anticoagulants.

According to members of Truman’s ADE team, having pharmacists fully integrated into the care team and accomplishing housewide education on adverse drug reactions have been key to addressing ADEs. With these two practices in place, providers are better able to anticipate when and where adverse events may happen and prevent them.


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