Improvement of medication event interventions through use of an electronic database.
OBJECTIVE
Patient safety enhancements achieved through the use of an electronic Web-based system for responding to adverse drug events (ADEs) are described.


CONCLUSIONS
A two-phase initiative was carried out at an academic pediatric hospital to improve processes related to "medication event huddles" (interdisciplinary meetings focused on ADE interventions). Phase 1 of the initiative entailed a review of huddles and interventions over a 16-month baseline period during which multiple databases were used to manage the huddle process and staff interventions were assigned via manually generated e-mail reminders. Phase 1 data collection included ADE details (e.g., medications and staff involved, location and date of event) and the types and frequencies of interventions. Based on the phase 1 analysis, an electronic database was created to eliminate the use of multiple systems for huddle scheduling and documentation and to automatically generate e-mail reminders on assigned interventions. In phase 2 of the initiative, the impact of the database during a 5-month period was evaluated; the primary outcome was the percentage of interventions documented as completed after database implementation. During the postimplementation period, 44.7% of assigned interventions were completed, compared with a completion rate of 21% during the preimplementation period, and interventions documented as incomplete decreased from 77% to 43.7% (p < 0.0001). Process changes, education, and medication order improvements were the most frequently documented categories of interventions.


CONCLUSIONS
Implementation of a user-friendly electronic database improved intervention completion and documentation after medication event huddles.
Jenna Merandi, Pharm.D., M.S., is Medication Safety Coordinator; Shelly Morvay, Pharm.D., is Medication Safety Coordinator; Dorcas Lewe, M.S., RN, is Quality Improvement Services-Clinical Coordinator; Barb Stewart, B.S., RN, is Quality Improvement Services-Clinical Coordinator; Char Catt, M.S., RN, is Vice President of Clinical Services; Phillip P. Chanthasene, B.S., is Systems Analyst; Richard McClead, M.D., is Medical Director, Quality Improvement Services; and Karl Kappeler, M.S., B.S.Pharm., FASHP, is Director, Pharmacy Services, Nationwide Children's Hospital, Columbus, OH. Jay M. Mirtallo, M.S., B.S.Pharm., BCNSP, FASHP, is Professor of Clinical Pharmacy and Director, M.S. in Health-Systems Pharmacy program, Division of Pharmacy Practice and Administration, College of Pharmacy, The Ohio State University, Columbus.
Jenna
J
Merandi
Shelly
S
Morvay
Dorcas
D
Lewe
Barb
B
Stewart
Char
C
Catt
Phillip P
PP
Chanthasene
Richard
R
McClead
Karl
K
Kappeler
Jay M
JM
Mirtallo
D064420:Drug-Related Side Effects and Adverse Reactions / Q000175:diagnosis / Q000517:prevention & control; D057286:Electronic Health Records / Q000592:standards* / Q000639:trends; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control* / Q000639:trends; D008510:Medication Systems, Hospital / Q000592:standards* / Q000639:trends; D058996:Quality Improvement / Q000592:standards* / Q000639:trends