Leveraging Rules and Alerts to Improve Patient Safety and Clinical Pharmacy Services

1. Leveraging Rules and Alerts to Improve Patient Safety and Clinical Pharmacy Services Sonali Muzumdar Pharm.D., CPHIMSInformatics PharmacistMercy Hospital and Medical CenterComprehensive Pharmacy Services

2. Objectives • Describe a method to assist pharmacist identification of changing renal function over time for patients on renally adjusted medications • Identify a method to improve patient safety by preventing medication errors associated with documented weight changes • List pharmacy clinical services that can be improved by use of rules and alerts

3. Audience Poll How many sites have CPOE?

4. Mercy Hospital & Medical CenterChicago, Illinois

5. Mercy Overview • History and Mission • MAPS Timeline • Applications • Healthcare Information Management & Systems Society • Stage 6 Hospital Recognition • The Leapfrog Group

6. Quick Facts 479 Licensed Beds 286 Staffed Beds 16,353 Annual Inpatients 14 Offsite locations 252,630 Outpatient Visits 56,172 ED Visits 1,503 FTE’s 100 Interns and Residents

7. EHR Applications (Cernerize) • PharmNet • FirstNet • APACHE • CareAware • CareMobile • Discern Expert/Explorer • BMDI/Open Port • CPOE • ProFile - HIM • Foreign System Interfaces • Knowledge Catalog • M Pages • PowerChart • E-prescribe • Power Note • PowerPlans • PowerOrders • CareNet • SurgiNet / Anesthesia • RadNet • ProVision Web • I-Net • NHIQM Dashboard

8. Pharmacy Team • 15 Clinical Pharmacists • 6 Clinical Specialists • 2 Internal Medicine • 2 Emergency Medicine • 1 Ambulatory Care • 1 Critical Care • 2 Pharmacy Practice Residents • 1 Informatics Pharmacist (0.6 FTE) • DOP, ADOP, Clinical Manager • 20 FTE pharmacy technicians

9. Pharmacy Clinical Services • Renal dosing • Automatic IV-PO conversion • Anticoagulation management service • Pharmacokinetic monitoring • Inhaler training • Anticoagulant counseling • Medication profile review

10. JCAHO Recommendations • Safety alerts should help clinicians determine urgency and relevancy. • Review skipped or rejected alerts as important insight into clinical practice. • Review appopriate documentation to determine which which alerts need to be a hard stop. http://www.jointcommission.org/assets/1/18/SEA_42.PDF

11. JCAHO Recommendations • After implementation, continually reassess and enhance safety effectiveness and error-detection capability, including the use of error tracking tools and the evaluation of near-miss events. • Maximize the potential of the technology in order to maximize the safety benefits. http://www.jointcommission.org/assets/1/18/SEA_42.PDF

12. Outline • Mercy Hospital and Medical Center Overview • Renal Rule • Weight Change • Anticoagulant Counseling • Anticoagulant alerts

13. Renal Dosing Gap Identified

14. History • McCoy et al • Population: adult inpatients with acute kidney injury • Intervention: interruptive alert to modify medication therapy • Conclusion: Increased rate and timeliness of modification or discontinuation of targeted orders McCoy et al. Am J Kidney Dis 2010. 56:832-41

15. Renally Adjusted Medications • Acyclovir, Valacyclovir • Alendronate • Allopurinol • Amphoteracin • Beta-lactams • Bivalirudin • Ciprofloxacin, Levofloxacin • Colchicine • Colistin • Dabigatran • Enoxaparin, Fondaparinux • Famciclovir, Ganciclovir • Famotidine, Ranitidine • Fluconazole, Voriconazole • Hydroxyurea • Ketorolac • Levetiracetam • Lithium • Memantine • Metformin • Methylnaltrexone • NRTIs • Oprelvekin • Quinidine • Rifabutin • Sotalol • Spironolactone • Tetracycline • SMX-TMP • Zoledronic acid

16. RIFLE Criteria Bellomo et al. Crit Care 2004. 8:R204-212

17. Pilot Testing

18. Design of Renal Rule

19. Real time testing • Have the alert go to your email • Review rules prior to turning them on for the department • Review alert fatigue

20. Testing/Building Rules • Evaluate encounter specificity • Evaluate the medication order type

21. Task List Example

22. Interventions

23. Quality Improvement Data • Reported quarterly to Medication and Nutrition Committee • Data for one week’s audit • Task fired 49 times • 17/49 had medications that needed adjustment

24. Ongoing Changes • Utilize Cockcroft-Gault Creatinine Clearance (CrCl) • Medication specific CrCl cutoffs

25. Outline • Mercy Hospital and Medical Center Overview • Renal Rule Task • Weight Change Task • Warfarin Counseling Task • Senior ED Task

26. Audience Poll Who has a weight problem?

27. ISMP Best Practice for 2014 • Measure and express patient weights in metric units only. • Ensure that scales used for weighing patients are set and measure only in metric units. • Numerous medication errors have been reported http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf

28. Importance of a Correct Weight • Affects drug dosing • Drugs dosed in mg/kg, mcg/kg/min • Drugs dosed based on BMI & BSA • Cockcroft-Gault formula • Dietary requirements • Monitoring heart failure patients

29. Documentation Errors • Pounds instead of kilograms • Typographical errors (105 cm vs 150 cm) • Height & Weight numbers are transposed • Estimated weight is never updated • Another patient’s weight entered in the system ISMP newsletter. August 2010.

30. Medication Error Example • Order: panitumumab IV every 3 weeks • Usual dose: 6 mg/kg every 2 weeks • Clinical trial dose: 9 mg/kg every 3 weeks • Height (cm) was entered as the weight and the weight (kg) was entered as the height • Result: the patient received about 650 mg more panitumumab than intended for the first dose of therapy ISMP newsletter. August 2010.

31. Height & Weight Documentation

32. Documenting Weight Based Drips Clinical Weight automatically defaults for weight based dosing

33. Height & Weight Documentation

34. Medication Safety Committee Review • Current Height/Weight form does not alert the user if there is a weight change from previous documentation • Potential for error exists during documentation • Pharmacy should be notified if there is a significant weight change

35. Design of Weight Task Rule

36. Future Height & Weight Documentation

37. Pharmacist Clinical Process • Task fires • Pharmacist communicates with the RN to reweigh the patient • Update clinical weight • Review patient profile • Correct dose and/or interval

38. Outcomes of the Weight Task • Old incorrect weight: 120 kg • New correct and verified weight: 100 kg • Heparin infusion and boluses • 80 units/kg bolus (9600  8000 units) • 40 units/kg bolus (4800  4000 units) • Rate 18 units/kg/hr to 21.6 units/kg/hr (mL/hr remains unchanged) • Enoxaparin • 120 mg Q12H to 100 mg Q12H • Cefepime • 2 gram Q8H to 2 gram Q12H

39. Monthly Pharmacy Weight Tasks

40. Weight Task Changes • Averaging 15 tasks per week • Significant pharmacist time • Correction did not occur quickly • Alert for RN/CNA built

41. Alert for nurse and cna

42. Outline • Mercy Hospital and Medical Center Overview • Renal Rule Task • Weight Change Task • Anticoagulation Counseling Task • Anticoagulant Alerts

43. Warfarin Counseling Goals • Department goal • 50% of inpatients receive warfarin counseling • Assist in documentation • National Hospital Inpatient Quality measures • VTE-5: Venous thromboembolismwarfarin therapy discharge instructions • Compliance • Dietary advice • Follow-up monitoring • Potential for adverse drug reactions and interactions

44. Warfarin Counseling Task Process

45. Quality Measure Documentation

46. Improvement in Patient Counseling % Patients counseled from Jan 2012-Dec 2013

47. Limitations of the task list • Task list is not front & center for the pharmacists • Keeping up with the task list • Duplicate tasks

48. Outline • Mercy Hospital and Medical Center Overview • Renal Rule Task • Weight Change Task • Warfarin Counseling Task • Anticoagulation safety

49. Audience Poll Does your EHR alert you when your patient has received an epidural morphine injection and enoxaparin is ordered?

50. Black Box Warning WARNING: SPINAL/EPIDURAL HEMATOMA • Epidural or spinal hematomas may occur in patients who are anticoagulated with low molecular weight heparins (LMWH) or heparinoids and are receiving neuraxial anesthesia or undergoing spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients for spinal procedures. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include: • Use of indwelling epidural catheters • Concomitant use of other drugs that affect hemostasis, such as non-steroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants • A history of traumatic or repeated epidural or spinal punctures • A history of spinal deformity or spinal surgery