Hospital's ADE system improves medication safety, cuts costs

Length of stay also decreased

Saint Joseph Regional Medical Center of Mishawaka, IN, has an adverse drug event (ADE) alert system that has resulted in decreased severity-adjusted mortality rates, length of stay (LOS), and drug costs since it was implemented more than five years ago.

The hospital is part of Trinity Health, a large, multistate Catholic health care system. Trinity has been working for seven years on installing electronic medical records in all of its facilities, and the adverse drug alert system has been a part of that effort, says Jason P. Jablonski, RPh, director of pharmacy, respiratory therapy, sleep disorders center, and neurodiagnostics at Saint Joseph.

"Our pharmacy department cost-per-person went down from $867 to $826, and we didn't have any changes in staffing because of the alert system," Jablonski says.

Jablonski and co-investigators conducted a retrospective observational study evaluating the effects of the ADE alert system in seven Trinity Health network hospitals. They found that an external control group had increased pharmacy drug costs for the same period, with costs rising from an average of $734 to $797 per patient.1

The study also found a significant decrease in severity-adjusted mortality rates in the study ADE alert system group. Also, severity-adjusted LOS decreased significantly in the study group.1

The ADE alert system relies on programmed rules regarding drug use. The study outlined 17 rules that were used to trigger an ADE alert.

"The 17 alerts are part of the package," Jablonski says.

For instance, rule 1 involved the use of digoxin, magnesium, and potassium products. It states that the alert is triggered when digoxin is ordered. The alert prompts clinicians to check the patient's laboratory values for low serum potassium (< 3.4 meq/L) or low serum magnesium (< 1.3 meq/L) concentrations or elevated digoxin concentration (> 2.2 ng/mL). The alert also states that if the patient's electrolyte level is low, then current orders should be checked for the absence of potassium or magnesium supplementation.1

"It would say, 'You just entered an order for digoxin, and your patient has low potassium or low magnesium, and there are no supplementation of potassium or magnesium ordered,'" Jablonski explains. "So you then call the doctor and tell him or her that the patient's potassium is low and will get lower."

The goal is to prevent an ADE, he adds.

The second rule is similar, but pertains to when the patient, perhaps already on digoxin, has a high digoxin level.

"If the patient was on digoxin and the lab work drawn three days later showed low potassium or magnesium, then this would produce an alert that would warn the pharmacist that they should contact the physician," Jablonski says. "They should let them know about the low magnesium or potassium and that supplementation would be in order."

Other alerts pertain to drugs that might cause hyperkalemia, high serum creatinine concentration, low serum albumin concentration, ketorolac, elevated liver enzymes, drug-induced delirium, low platelet counts, low absolute neutrophil count, and major sedative properties.1

"Rules three and four are sister orders," Jablonski says. "The alert triggers when you order a drug that might cause hyperkalemia."

So if a physician orders a potassium-sparing drug or a diuretic, causing the potassium to increase to > 5.4 meq/L, then the alert will ask why a product is being ordered that will make the potassium rise even more, he explains.

The fourth alert triggers when the patient's serum potassium concentration is > 6.0 meq/L. In this case, the alert will suggest that maybe the patient should no longer be given a potassium supplementation, he says.

The fifth and sixth rules involve renal drugs.

"The alert looks at all drugs that need renal adjustment," Jablonski says.

For instance, the fifth rule's alert is triggered whenever drugs that are excreted renally are ordered, except for one-time orders.1

Lab results from the previous seven days are checked for high serum creatinine concentration.1

The 17 rules are standard ADE rules for the electronic ADE alert system, but health care facilities can select whichever medication rules they want to use, Jablonski says.

"We've done a lot over the years to tweak them and make them more specific so we won't get a lot of false positives," he explains. "Like with the renal rule, it doesn't look to see if the drug has already been adjusted."

Also, as the health system's electronic medical record has come on line, the pharmacy department can do so many more medication safety initiatives, he says.

"This was phase one, an elementary safety process we implemented years ago," Jablonski says. "We were trying to measure if there was any value in the process."

What they found was that over time the alerts trained the staff. While they might have used the alerts to inform their decisions initially, over time they incorporated the rules in their work.

For instance, the rule 17 is an alert triggered whenever a dose of amitriptyline ≥ 50 mg is ordered for a patient who is 65 years of age or older. As clinicians became familiar with this rule over time, they stopped ordering amitriptyline as frequently, Jablonski says.

Another advantage of the alerts is that pharmacists can rely on these to warn them if a patient's lab values worsen while on drugs that are renally excreted, he notes.

"It's an automatic surveillance," he adds. "Before, hospitals would each day receive a report from the lab showing all serum levels."

Another change taking place is that some of the alerts now are being transformed into more dramatic alerts that will pop up on the computer screen when clinicians are keying in a drug order.

The ultimate goal is to send physicians a message each time they prescribe a drug. The message would address whether the particular drug therapy is relevant, and it would outline the drug's potential side effects and how it might impact the patient's care.

"Some day, we'll have a truly smart system that will prevent ADEs from ever happening before they get off the ground," Jablonski says. "If a physician tries to order warfarin, and there is no baseline PTNR, then it will pop up on the screen and say, 'You can't proceed until you order this lab.'"

The electronic ADE system is moving in this direction, but still has some distance to go, he adds.


  1. Piontek F, Kohli R, Conlon P, et al. Effects of an adverse-drug-event alert system on cost and quality outcomes in community hospitals. Am J Health Syst Pharm 2010;67:613-620.