Improvement of medication event interventions through use of an electronic database

Abstract

Implementation of a user-friendly electronic database improved intervention completion and documentation after medication event huddles.

Implementation of a “second victim” program in a pediatric hospital

“…6 Through the huddle process, the patient safety team identified the presence of second victims in the organization-regardless of whether the event reached a patient and caused harm or was caught prior to reaching a patient. While patient safety continues to be the main focus, it is imperative that employee safety is considered and addressed as well.…”

Preventability of Voluntarily Reported or Trigger Tool-Identified Medication Errors in a Pediatric Institution by Information Technology: A Retrospective Cohort Study

“…Operating rooms in the inpatient setting utilized a separate EHR with CPOE (although some orders were still transcribed), but this system did not directly connect to Epic, did not have the CDS capabilities of Epic, and barcoding technologies were not used for all medications administered during procedures. The NCH healthcare network utilized an electronic AE monitoring system where patients, families, and clinicians could enter any ADEs, ADRs, potential ADEs, and medication errors identified during routine care [25]. In addition, an automated trigger tool system was used to detect common medication adverse effects without the need for voluntary reporting (e.g., the use of reversal agents and addition of laxatives for opioid-induced constipation would be automatically collected in the trigger tool database) [7,26].…”

“…Although reporters categorized medication error severity, the authors independently used the National Coordinating Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors (NCCMERP) to determine the severity of the error [29]. The independent review was completed to ensure accuracy of reports and increase external validity as the NCH reporting system used a slightly modified severity index [25]. This NCCMERP index categorized medication errors from A to I based on the severity of the outcome, as follows:…”

“…We utilized two data sources to help provide more complete data, rather than using only trigger tool-identified events or only reported events [38,39]. While the safety culture at NCH allowed for high rates of error and ADE reporting as described in previous studies [7,25], institutions should always strive to continually improve the completeness of error and ADE voluntary reporting. There were also changes in the safety culture and systems at NCH during the study period [7], which may have affected our results.…”