The Missouri Baptist Medical Center learned important lessons about patient safety when it began using IHI’s Trigger Tool for Measuring Adverse Drug Events (ADEs).** Putting those lessons into practice, the 489-bed facility in St. Louis, Missouri, cut the average number of ADEs per 1,000 doses from almost 2.0 in May 2001, when it started using the tool, to less than 0.5 by the summer of 2003.
The Trigger Tool is a list of 24 potential problems that can result from using certain medications. When noted in medical charts, these “triggers” alert a reviewer to the possibility that an ADE might have occurred.
Missouri Baptist learned that having a multidisciplinary team that includes a pharmacist, a nurse, and a physician who use the tool when reviewing charts is an effective way to identify and quantify adverse events, says Nancy Kimmel, RPh, a patient safety specialist at the medical center.
The team also found that neither patients nor staff were being educated adequately about the proper administration of insulin, anticoagulants, and narcotics. So the center assigned a group of professionals to work on reducing ADEs involving these high-risk medications. “Each one of these groups manages a different high-risk medication, for which they do patient and staff education, assessment, documentation, and treatment,” Kimmel explains. “Now if we see a trigger or an adverse event, the information can be filtered to that group because they know how to correct the process.”
Another important lesson came when the medical center automated 14 of the 24 processes involved in the chart review. The information system now alerts the pharmacist when it identifies a potential adverse event.
“All of this information has always been in the chart,” says Kimmel. “But now we can see the data and respond so that we’re seeing fewer adverse events per 1,000 doses dispensed.”
**An interactive version of the Trigger Tool for Measuring ADEs is also available.
