Joint Commission: Real-time surveillance dashboards assist med safety

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Real-time pharmacy surveillance of high-alert medications increased the likelihood of intercepting medication errors, according to a six-month study published in the July issue of the Joint Commission Journal on Quality and Patient Safety.

Lemuel R. Waitman, PhD, and colleagues, designed and analyzed a dashboard surveillance tool for monitoring aminoglycosides, warfarin and anticoagulants by clinical pharmacists, to assess its potential value in identifying and intercepting possible adverse drug events. The system was designed to operate independently of computerized provider order entry and clinical decision support, but also complement the two, by serving as a “safety-net” to intercept medication errors. The web-based application organized patient data onto dashboards on the basis of provider-entered orders for high-alert medications, and identified a number of alerts for each medication.

Researchers analyzed the usage of aminoglycoside, heparin/enoxaparin, and warfarin dashboards from April 2009 to September 2009, and calculated exposure to medication orders and alert criteria for each hospital patient encounter. Three alerts were identified with the use of warfarin, six for aminoglycosides and seven for heparin and enoxaparin. Of 28,929 adult inpatient admissions and observation encounters at Vanderbilt University Medical Center in Nashville, Tenn., during the study period, 2,224 patients were exposed to warfarin, 8,383 to heparin or enoxaparin, and 893 to aminoglycosides.

Results of the study indicated that pharmacy use of dashboards led to numerous patient safety-related interventions. Pharmacists were able to notify the clinical team about suboptimal medication orders, incorrect drug dose adjustments or inadequate monitoring. "On the basis of interpharmacist communication and EMR notes recorded within the dashboard, interventions were frequent," wrote Waitman et al.

Results also indicated that clinical pharmacists reviewed the warfarin and aminoglycoside dashboards 100 percent of the days in the study period, while heparin and enoxaparin dashboards were reviewed 71 percent of the days. The most common alerts occurred on the aminoglycoside dashboard and concerned missing or delayed monitoring of serum creatinine, according to the study.

Dashboards were configured to specify enrollment criteria—drug exposures, laboratory results—that determine when a patient populates a dashboard, according to the authors, as well as how long after exposure a patient remains on the dashboard. They also contained specific data sets and defined alert conditions, such as laboratory results, orders or absence of monitoring.

“The real-time surveillance tool successfully synthesizes data in real time, prioritizes patients on the basis of predefined clinical data rules and facilitates pharmacist-to-pharmacist and pharmacist-to-clinical team communication,” wrote Waitman et al. “ In a healthcare system where each of the dashboard medications already relied on advanced initial dosing decision support during the time of this study, our initial experience with implementation shows a high rate of use and need, with frequent monitoring (100 percent) for warfarin and aminoglycosides (but not heparin/enoxaparin), and a substantial number of care interventions by clinical pharmacists.”

Researchers noted possible applications for real-time dashboard surveillance in a variety of settings. Pediatric pharmacists could use dashboards to better monitor the use of coagulants. Infection control teams could use them to take advantage of newly-released microbiology reports and specialists could use them to monitor complex drug-disease interactions. Dashboard surveillance could also assist clinical pharmacists with expanding the scope of their practices and speed of their reactions to potential adverse drug events. Additionally, it could help foster collaboration with primary care teams to enhance therapy optimizations, the authors suggested.

“Continued surveillance of high-risk patients through improved data aggregation and visualization should allow pharmacists to increase specificity above existing clinical decision support with automated rule-based alerts for complex conditions,” Waitman and colleagues concluded.