Using Key Performance Indicators
(KPIs) from Medication Reconciliation
(MR) to Quantify and Prevent Future
Adverse Drug Events (ADEs)
Stephen Lim, TT Chih, E Fong
Pharmacy,
Armadale Health Service
Delivering a Healthy WA
Armadale Health Service
(AHS)
Overview:
• Med Rec (MR) in AHS
• Aim and Method to quantify MR
• Definition of:
– Adverse Drug Events (ADEs)
– Key Performance Indicators (KPIs)
• Achievements of KPIs
• Prevention of future ADEs
• Lesson learnt
Med Rec (MR) in AHS
•
•
•
•
•
•
Since 2007
SQuIRe funded project
Marketed as Med Matching (M+M) program
70-90% M+M for all admitted patients
Sustainable program
Common errors in MR
Common Drug Errors in MR
60
52.5
50
Exclude ADR documentation
40
30.3
30
20
15.3
10
1.9
0
Wrong drug
Med Duplication Med Omission
Wrong dose
Aims and Method to Quantify MR:
• Aims:
– To quantify success or failure in MR
– Use KPIs to  or prevent ADEs
• Method:
– Daily data collection from MR activities
– Analyse data monthly using 4 KPIs
Definition of ADEs:
(Adverse Drug Events Ξ Actual Drug Errors)
• Potential Drug Errors:
– MR < End of Next Calendar Day (ENCD)
– near misses (rectified before drug admin)
– Not counted as ADEs
• Actual Drug Errors:
– MR > ENCD
– Counted as ADEs due to:
• Med not admin (Rx omission)
• Wrong drug/dose admin (incorrect Rx)
Case study (patient AO, 70y, ♀)
ADE Ξ Adverse Drug Events Ξ Actual Drug Errors
NIMC
NIMC dose
BPMH (Best Possible
Med History)
Dose admin?
Aspirin (commission error)
100mg mane
Ceased months ago
1 dose (ADE √)
Mirtazapine (commission
error)
15mg nocte
-ditto-
1 dose (ADE √)
Tamoxifen (commission
error)
20mg nocte
-ditto-
1 dose (ADE √)
Calcium (omitted Vit D)
1d
Ca plus Vit D
1 dose omitted (ADE √)
Frusemide
40mg m
20mg mane
Intentional dose change
(ADE X)
Olmesartan (omitted HCT)
40mg mane
Olmesartan + HCT 40/12.5mg mane
1 dose omitted (ADE √)
Prochlorperazine
5mg mane
(wrong dose)
5mg tds
2 doses missed (ADE √)
Fosamax plus (commission
error)
1 weekly
Ceased months ago
Not admin (ADE X)
Definition of 4 KPIs:
• KPI1 = ADEs per 1000 doses administered
Number ADEs ÷ Number med doses admin (30 random patients/month) X
1000
• KPI2 = ADEs per 100 med written (Rx)
Number ADEs ÷ total med written X 100
• KPI3 = Pharmacy Interventions per 100 patients
Total pharmacist clinical interventions ÷ total MR patients X100
• KPI4 = ADEs per 100 patients seen >ENCD
Number ADEs ÷ total MR patients X 100
ACHIEVEMENT : KPI1 ADEs per 1000 doses
Average 4.7 ADEs per 1000 doses
= 1 ADE per 200 doses
Trendline
 ADEs
ACHIEVEMENT: KPI2 ADEs per 100 med Rx
25
17 drug errors for every 100 meds written
20
% med discrepancies
Percentage
% actual ADEs
15
10
13 ADEs prevented due to MR
4 ADEs for every 100 meds written
5
Trendline
 ADEs
0
May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10
ACHIEVEMENT: KPI3 Pharmacy Interventions per 100
patients
Pharmacy interventions per 100 admissions
300
122 clinical interventions
per 100 patients
250
Total interventions
Med Rec interventions
240
210
200
64 MR activities
per 100 patients
170
150
140
126
121
116
100
87
73
60
50
40
90
Trendline
 MR
69
58
45
26
35
40
38
110
108
45
0
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
KPI4: ADEs per 100 admissions
(Do Nothing KPI!)
160
83 ADEs per 100 patients
(MR > ENCD)
140
120
100
80
60
40
Flat trendline:
Error when no MR
20
0
May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar09
09
09
09
09
09
09
09
10
10
10
Prevent Future ADEs:
• Goal:
•  ADEs to  harm:
– KPI1
–  KPI2
– ↑ KPI3
– KPI4
Lesson learnt:
Lesson learnt:
•
 KPI1 and KPI2 (≠ 0 ADE):
•
•
•
↑ KPI3:
•
•
timely Med Rec (within ENCD)
involve all clinicians in MR
50% clinical pharmacist workload is MR related
KPI4 remains constant if no MR
•
0.8 ADE per patient
Assigning Risk Rating to ADEs
ADEs Risk Ratings
5% 0%
38%
57%
Risk rating 0
Risk rating 1
Risk rating 2
ADEs risk rating: from 0-3
0 = near miss
1 = low (no harm has occurred)
2 = moderate (extra monitoring
eg. digoxin level had to be
ordered, extra obs (BP/BSL)
needed, Dr reviewed patient,
no extra treatment required).
3 = severe (required extra
treatment, t/f to another
hospital/unit, ↑ LOS,
readmission)
Risk Rating 3
Conclusion:
• To  ADEs:
• Timely Med Rec within ENCD
• Involve all clinicians in MR