Fit the approach to the type of location
Fit the approach to the type of location
One prevention program doesn’t fit all
Officials at Fallon Healthcare Systems in Worcester, MA, have developed a tracking and prevention program unique for its integration of data, which covers both inpatients and ambulatory care patients.
Fallen is a 363-bed, acute care hospital that operates its own health maintenance organization, integrating databases for both types of patients and between medical and pharmacy departments. Fallon developed different approaches for each patient setting, while each houses a specific pharmD clinical coordinator to compile data, compare them, seek out trends, and offer solutions.
For its inpatient population, an alerting order system was established that notifies a pharmacist when monitoring is required. When drugs are used that have a history of adverse reactions, for example, pharmacists are called in to review. Drugs such as diphenhydramine, protamine, and epinephrine, for example, fit that category.
Abnormal lab results, more easily captured with an integrated database system, also lead to mandatory review. Those data are then compiled by the inpatient clinical coordinator as part of the patient’s record.
For Fallon’s outpatient setting, a voluntary reporting system was developed, based on broad criteria and a nonpunitive approach. To promote compliance, the system is called an information-gathering system. That approach was based on simple realities: more patients, patients who pay out of pocket, and those whose monitoring time frame is not uniform.
Therefore, the voluntary system urges clinicians to report every instance of a suspected or confirmed adverse reaction, no matter how small it seems. The system’s definition of an adverse reaction reads, "Any response to a drug that is undesirable, unexpected, and occurs at doses normally used for the prophylaxis, diagnosis, or treatment of disease."
To save paperwork and time, postcard-size forms are used that ask for a patient’s name, the date, the suspected drug, and a reaction description. From there, clinical coordinators review every report to determine any trends or course of action. Reports are compiled and held in the database, where the inpatient and outpatient information is shared.
Other educational efforts include sending "Dear Doctor" or related clinical advisories to prescribers, distributing laminated dosing cards throughout the system, and printing updates in Fallon’s in-house newsletter.
Guidelines can motivate
For health care systems having trouble starting a program gaining staff acceptance, medication error specialists promote existing pharmacy organization and think tank guidelines on tracking and reporting.
Guidelines published in 1995 by the American Society of Health-System Pharmacists (ASHP), for instance, are part of Fallon’s adverse reaction program. Those recommendations include monitoring high-risk drugs before their use, identifying high-risk patients, using alert orders calling for pharmacists’ monitoring, and using specific drugs to treat common adverse reactions (antihistamines, epinephrine, or corticosteroids, for example.)
The ASHP guidelines define high-risk patients as geriatric or pediatric patients, those with organ failure, or those receiving multiple drugs. The organization defines high-risk drugs as aminoglycosides, amphotericin, antineoplastics, corticosteroids, digoxin, heparin, lidocaine, phenytoin, theophylline, thrombolytic agents, and warfarin.
The guidelines also cover the increasingly accepted approaches, such as multidisciplinary teams including physicians, nurses, administrators, and pharmacists. The guidelines urge pharmacists to take leadership roles in the development of error tracking and reporting programs, and to report problems to the FDA, drug makers, and peers outside of their hospital’s walls.
[For more details, contact: The U.S. Pharmacopeial Convention, Rockville, MD. Telephone: (301) 881-0666. Leslie Fish, PharmD, or Laurie Fromm, PharmD, Fallon Healthcare Systems, 25 Winthrop St., Worcester, MA 01604. Telephone: (508) 852-0600. The American Society of Health-System Pharmacists in Bethesda, MD. Telephone: (301) 657-3000.]
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