Welcome to the New England QIN-QIO Medication Safety Webinar!

Transcription

1 Welcome to the New England QIN-QIO Medication Safety Webinar! Thank you for joining. Our presentation will begin shortly. If you haven t already, please dial in to the audio line by calling: Passcode: /25/2015 1

2 Dangers of the Daily Dose. Medication Safety New England QIN-QIO Medication Safety and Adverse Drug Event Prevention Margherita R. Giuliano, R.Ph., CAE Medication Safety Lead NH, VT & CT, NE QIN-QIO Lori Nerbonne, BSN, RN Nursing Home & Safe Transitions - MA, NE QIN-QIO Stefan Gravenstein, MD, MPH, CMD Safe Transitions & Medication Safety Clinical Director, NE QIN-QIO Pamela Quinn - RN, CPHQ Medication Safety Lead - RI, NE QIN-QIO June 25, :00am 12:00pm This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (NE QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy CMSQIN_C3-2_201506_0099

3 Continuing Education The Connecticut Pharmacists Association is accredited by the Accreditation Council of Pharmacy Education as providers of continuing pharmacy education. Pharmacists in attendance who participate in this session and then complete the on-line evaluation can receive up to 1 contact hour of credit. Knowledge based activity: UAN L05-P This Continuing Nursing Education Activity was Approved by the Northeast Multi-State Division, An Accredited Approver by the American Nurses Credentialing Center s Commission on Accreditation. Program: / Approved Contact Hour(s): 1.0 Questions regarding CE status may be submitted to Ileizy Victor at Ivictor@healthcentricadvisors.org 6/25/2015 3

4 Speaker Disclosures Today s speakers have no conflicts of interest to disclose In adherence to the regulation standards of the Connecticut Pharmacists Association, the Accreditation Council of Pharmacy Education, Northeast Multistate Division (NE-MSD) and the American Nurses Credentialing Center s Commission on Accreditation this notice confirms that the information contained in this presentation is free of commercial bias and the speakers have no related vested financial interest in any capacity, inclusion of shareholder, recipient of research grants, consulting or advisory committees. 6/25/2015 4

5 Learning Objectives By the end of the session, participants will be able to: Identify the primary goal for CMS Medication Safety and Adverse Drug Event Prevention (ADE) Program; Identify three ways that CMS Medication Safety and ADE Prevention Program aligns with the Department of Health and Human Services National Action Plan for ADE Prevention; Differentiate between an ADE, a potential ADE (pade) and a medication error; Understand the importance of measuring potential and actual adverse drug events; and Identify two ways to improve care transitions through the implementation of medication safety programs. 6/25/2015 5

6 Marghie Giuliano, R.Ph., CAE Medication Safety Lead CT, NH, VT New England QIN-QIO Executive Vice President, Connecticut Pharmacists Association Served on the national advisory panel that developed Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0 Serves on various national and state health care task forces Published Health Affairs, 2011 : In Connecticut: Improving Patient Medication Management in Primary Care 6/25/2015 6

7 Stefan Gravenstein, MD, MPH, CMD Clinical Director, NE QIN-QIO Professor of Medicine and Director, Center for Geriatrics and Palliative Care Case Western Reserve University Authored over 100 peer-reviewed articles (influenza, vaccination, transitions of care, quality improvement & measurement) Fellow of the American College of Physicians and American Geriatrics Society Serially ranked one of the nations Best Doctors for geriatrics 6/25/2015 7

8 Lori Nerbonne, BSN, RN Nursing Home & Safe Transitions - MA NE QIN-QIO Patient and family advocate Nurse with background in Regulatory Compliance, Patient Advocacy and Quality Improvement 6/25/2015 8

9 Pamela Quinn, RN, CPHQ Medication Safety Lead RI NE QIN-QIO Certified Professional in Healthcare Quality 40 years of experience in Long Term Care Person-Centered Care is her passion 6/25/2015 9

10 Chat In Is your organization focused on Medication Safety as part of your care transitions effort? Be sure to introduce yourself first - share your state, organization and role and then your efforts 6/25/

11 What system level pieces are necessary in order to ensure a safe transition for all patients? What system level pieces are necessary in order to ensure a safe transition for all patients? 6/25/

12 Dotty s Story Medication Safety & ADEs To date, data commonly implicate age as a principal underlying risk factor for ADEs. National Action Plan for ADE Prevention, US Dept. of Health & Human Services 6/25/

13 Steps Toward Prevention Anticoagulation Task Force Standardized, Safe Abbreviations Rapid Response Team Condition H (family calls Rapid Response) Open Medical Error Disclosure 6/25/

14 Which geriatric syndrome could be Adverse Drug Event (ADE)? Bleeding Confusion Fall All of the above Polling Question 6/25/

15 Scope of the Problem ADEs account for 1/3 of hospital adverse events 1 ADEs cause ~ 280,000 hospital admissions annually 1 Hospital admissions related to ADEs in adults > 65 years was 24.9% 2 One-quarter of all ADEs are preventable 3 The CDC estimates that $3.5 billion is spent on extra medical costs associated with ADEs every year 1 U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention. Washington, D.C.: Koh, H. 2 Bourgeois FT, Shannon MW, Valim C, Mandl KD. Adverse drug events in the outpatient setting: an 11-year national analysis. Pharmacoepidemiology and Drug Safety. September 2010;19(9): Neumiller J, Corbett C. Prevention of Medication Errors in the Older Adult Patient. Postgraduate Healthcare Education, LLC. Power-Pak C.E. Mylan Pharmaceuticals, /25/

16 Ramifications System Ramifications Readmissions ER visits Physician Office visits Increased healthcare costs Patient Ramifications Increased patient harm Decreased quality of life Loss of patient productivity 6/25/

17 HHS National Action Plan for Adverse Drug Event Prevention Focus Anticoagulants; Diabetic Agents; and Opioids Approach Surveillance; Prevention; Incentives & Oversight; and Research. 6/25/

18 Surveillance Active versus Passive surveillance Active= proactive collection of information, primarily from health records, or databases Passive= relies on clinicians or patients to voluntarily report information Active surveillance: typically required to quantify scope and magnitude of health problem and assess trend 6/25/

19 Categorization of Medication Harm Adverse Drug Event (ADE) Defined as injury resulting from medical intervention related to a drug 6/25/

20 An ADE is an injury resulting from medical intervention related to a drug 6/25/

21 NCC MERP Index for Categorizing Medication Errors 6/25/

22 Surveillance How does your organization measure ADE? What is the rate of ADE for the Warfarin patients you manage? Patients with diabetes? How do you assess if the actions you take provide value or impact our ADEs? 6/25/

23 Adverse Events Many events are not attributed to meds - but could be (e.g., falls) Medication Errors Falls Adverse Drug Reactions Adverse Events Adverse Drug Events 6/25/

24 Chat In Falls occur in individuals who are 6/25/

25 Falling for the Art of ADE 1. Sedatives/hypnotics 2. Antihypertensives 3. Antipsychotics 4. Hyperglycemics 5. Anxiolytics/anti-agitation 6. Anticholinergics 7. Constipating and the list goes on. 6/25/

26 How many ADE s do you see in your facility each year? More than 100 Polling Question 6/25/

27 ADEs - Transitions of Care AAAs ASAPs SNFs Hospital to home - lack of communication Hospital to NH - medication changes NH to home - no prescriptions or too expensive * 6/25/

28 Why do ADEs Happen Incomplete medication profile Failure to consider underlying risk factors Failure to consider progressive nature of certain drug-drug interactions Lack of communication with patients and caregivers Failure to communicate when to stop taking medications Fragmented system Multiple providers Complex patients Polypharmacy Transitions of care 6/25/

29 Chat In What do you believe is the biggest opportunity to enhance medication safety during transitions of care? What recommendations do you have? 6/25/

30 Goals for NE QIN-QIO Medication Safety and ADE Prevention Program Improve medication safety and prevent ADEs Implement evidence based and proven best practices * 6/25/

31 Payors C-Suites, Opinion Leaders Home Health Agencies Nursing Homes Community -based services Hospitals Pharmacy Physician Offices Patient/caregiver 6/25/

32 Maintaining a Person-Centered Focus When should medication reconciliation be done? Upon admission During a floor or room change After every MD visit After every consult Prior to discharge 6/25/

33 Possible Interventions Organized and systematic process for data collection Medication reconciliation / synchronization Patient and caregiver education and engagement Individual practice setting areas of focus Discharge assessment for potential cognitive/cultural deficits impacting safe selfadministration of medication And many more. 6/25/

34 A Call to Action! We can do this! Monitor ADEs/pADEs Partner with providers across the spectrum Share data to identify system processes that work Participate in educational sessions (like these) to learn and lead * 6/25/

35 Conclusion Medication Safety is a critical component to enhance safe care transitions and reduce unplanned readmission Monitoring ADEs and pades is critical for prevention Good systems - create good outcomes * 6/25/

36 Chat In What topics would you like to explore in future sessions? Diabetic Standards Medication Reconciliation Medication Therapy Management Opioid Abuse Opioid Prescribing Warfarin Management Other. 6/25/

37 Questions, Comments & Insights 6/25/

38 Resources / Tools Visit the New England QIN-QIO website at CDC - Medication Safety Programs ISMP - Regional Medication Safety Programs for Hospitals ISMP - Community Pharmacy Medication Safety Tools/Resources ASHP - Medication Safety Officer: Getting Started MUST Program for Seniors MARQUIS Toolkit for Medication Reconciliation Medications at Transitions and Clinical Handoffs (MATCH) Toolkit Community Pharmacy Medication Safety Tools and Resources: Medication Safety Officer: Getting Started 6/25/

39 Maine Alejandro Enriquez Zamalloa, PharmD, MS X 3108 Massachusetts Melissa Pollock, PharmD, CGP, RPh mpollock@healthcentricadvisors.org X3202 Rhode Island Pam Quinn, RN, CPHQ pquinn@healthcentricadvisors.org Contact Your Medication Safety State Lead Connecticut, New Hampshire & Vermont Margherita Giuliano, RPh, CAE mgiuliano@ctpharmacists.org Questions regarding CE status may be submitted to Ileizy Victor at Ivictor@healthcentricadvisors.org 6/25/