Purpose and Outcomes
This in-service session is dedicated to the issue of preventable adverse drug events and the importance of addressing them. Adverse drug events, or ADEs, including preventable ones, are responsible for a large number of hospitalizations, lengthened hospital stays and higher costs. Therefore, reducing the number of these events is essential for the reduction of patient harm and the lowering of costs within the healthcare system. This session’s desired outcomes include drawing the audience’s attention to the issue, providing data on how it can be addressed, and motivating the audience for action regarding the problem.
Preventable Adverse Drug Events: Root-Cause Analysis
ADEs are unintentional and harmful events related to medications that are a major concern of the system of healthcare. However, for strategic planning, it is important to concentrate on preventability, as policies not targeting factors linked to preventable events cannot contribute to the reduction of ADEs. Therefore, this study focuses on preventable ADEs, or pADEs, and will employ root-cause analysis to discover how these can be reduced. According to Hibbert et al. (2018), root-cause analysis, or RCA, is a set of approaches that use a structured process to create maps of relevant events, analyze data sources, and develop cause-and-effect charts and recommendations. This paper identifies the root causes of pADEs and translates the findings into actions that can be taken to prevent them from occurring.
Research Employed
It is widely recognized that the prevention of pADEs could tangibly improve public health. However, few studies have analyzed the root causes of pADEs with patients and providers interviewed to determine why they occurred. This study utilizes the findings of two groups of researchers: Woo et al. (2020) conducted a retrospective chart review, and De Lemos et al. (2021) performed a cross-sectional observational study. Woo et al. (2020) combined data from three different multi-center observational studies that evaluated ER patients for adverse drug events. De Lemos et al. (2021) interviewed patients, their families, and associated healthcare providers, after which they performed root-cause analysis to produce key learning messages; then, they designed an electronic reporting tool.
Root-Cause Analysis
One of the studies was a multi-center retrospective research and/or review of medical records administered in four acute care hospitals in Canada. Woo et al. (2020) examined the medical and/or research records of patients who had one or more problems related to medication or ADEs. When it comes to the factors contributing to pADEs, these were linked to prescribing and monitoring of medications, adherence barriers, communication problems, social factors, and insufficient access to adequate care (Woo et al., 2020). The single most frequently identified factor contributing to pADEs was reported to be insufficient education or instruction of patients. Common issues related to drug prescription were delays to or inadequate follow-up after drug replacement and inadequate laboratory monitoring. The most common adherence barriers were mental illness problems and patient preference.
Another research was a cross-sectional observational study that was conducted at a British Columbia urban community hospital for which patients were recruited from November 2016 to December 2017. The most common factors contributing to pADEs, as per De Lemos et al. (2021), were providers not ensuring the patient/family understands the information given to them and can identify how medications help them/solve their problems. Moreover, the patient/family often cannot determine whether medications work or have side effects. Other factors include the absence of sick-day management plans and other plans of the same kind and providers not evaluating the use of medication and monitoring competency.
Improvement Plan
The improvement plan is to employ a twofold approach, the first part of which is the development and distribution of learning messages to the community and providers. To be a candidate for a learning message, the theme needs to be able to be translated into specific actions that could be followed to reduce the recurrence of the pADE. The learning message is to not be considered complete until most potentially related pADE cases relevant to that message are reviewed by the committee. Messages are to be deployed in the form of documents for distribution to care providers in the local community. These messages are to also be presented orally at regular doctors’ meetings and a special meeting for community pharmacists and nurses. All provider messages are to be published digitally, and leaflets for patients and their families are to be published on local educational websites.
The second part of the approach is the construction of an electronic pADE monitoring-and-reporting system. Alongside the investigator committee, a key stakeholder, a health authority, is to engage in the development of this system. This includes the development of a key performance metric to calculate the rate at which weekly automated reports are to be prepared. In addition to that, plans are to be developed to improve reporting or referral of potential pADEs by target users (physicians, pharmacists and nurses). Finally, a reporting structure is to be created to share pADE reports with hospitals’ medical leadership and Patient Safety & Quality Committee. This reporting tool is to be accessible to any hospital provider from the hospital’s intranet.
Audience’s Role and Importance
As this presentation proved, nurses and their actions, however often they might be blamed for errors, are not the only or the main factor contributing to pADEs. Still, nurses can and should play a key role in preventing them from occurring. Therefore, it is important for the audience to get acquainted with the issue and learn about what can be done about it. By taking cognizance of and distributing learning messages and turning to pADE surveillance tool when necessary, nurses will significantly contribute to the success of the improvement plan. These actions will help them ensure fewer adverse events occur and, consequently, factor into their professional competence as healthcare providers.
References
De Lemos, J., Loewen, P., Nagle, C., McKenzie, R., You, Y. D., Dabu, A., Zed, P., Ling, P., & Chan, R. (2021). Preventable adverse drug events causing hospitalization: Identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.BMJ Open Quality, 10(1), 1-11.
Hibbert, P. D., Thomas, M. J. W., Deakin, A., Runciman, W. B., Braithwaite, J., Lomax, S., Prescott, J., Gorrie, G., Szczygielski, A., Surwald, T., & Fraser, C. (2018). Are root cause analyses recommendations effective and sustainable? An observational study.International Journal for Quality in Health Care, 30(2), 124-131.
Woo, S. A., Cragg, A., Wickham, M. E., Villanyi, D., Scheuermeyer, F., Hau, J. P., & Hohl, C. M. (2020). Preventable adverse drug events: Descriptive epidemiology. British Journal of Clinical Pharmacology, 86(2), 291-302.