Instruments for improvement aren't limited to tools

Sonja Quale
Sonja Quale

A 2014 report from the Office of Inspector General (Adverse Events in SNFs: National Incidence among Medicare Beneficiaries) revealed that one in three nursing home residents were harmed, if only temporarily, by an adverse event in the first 35 days of their skilled stay. Of these events, 37% were related to medications and 60% were preventable.  

In the years following publication of this report, many advances have been made, including education to reduce adverse events related to medications and the development of “trigger tools.” Most notably, in 2015, the Institute for Healthcare Improvement (IHI) piloted the Focused Survey on Medication Safety Systems, which used an adverse drug event trigger tool.  The tool was provided to surveyors for investigation and to nursing homes to use as a risk management tool.  The gauntlet had been thrown.

When I was first introduced to IHI's adverse drug event trigger tool, I thought it was great that we would have a simple way to easily identify adverse drug events that are most critical to our senior population. But after some independent research, I realized it was anything but simple. That's because the tool is a 14-page PDF document from CMS outlining 55 different potential adverse drug events and their identification criteria.  Practically speaking, how could it ever be successfully implemented?  

For an easier approach, organizations can take several steps to prevent adverse drug events:

  1. Focus on the highest risk medication categories. To make it simple, use the therapy classes reported in the MDS and build simple cheat sheets for how to identify potential adverse drug events:

  • Insulins

  • Anticoagulation

  • Antianxiety

  • Antidepressant

  • Antipsychotic

  • Hypnotics

  • Antibiotics

  • Diuretics

  1. Utilize your consultant pharmacist to ensure your facility has a process to complete a medication regimen review for residents being admitted for less than 30 days and for changes in condition.  As recommended in a December 2012 CMS memorandum2, this review may prevent errors due to drug-drug interactions, omissions, duplication of therapy or miscommunication during transition of care.  Absence of these procedures can lead to F-Tag 425 (see my blog post from December 2, 2016, for more information3).

  2. Leverage pharmacogenomics for your high-risk residents to ensure they are on the most appropriate medication that is not inadvertently causing harm because of their genetic metabolic characteristics. This step is especially helpful for anticoagulant (including clopidogrel) and pain management medications.  

Last, don't forget the importance of transitions of care. The first 35 days can also be thought of as the first “3 to 5 days” after admission, a critical period since early intervention is key to preventing adverse drug events.

If you automate your adverse drug event triggers, or establish the means to identify high-risk residents early on, and implement protocols to address the triggers, you'll improve your chances of reducing adverse drug events – and pick up the gauntlet.

In my next post, I will focus on high-risk medications and how to recognize and prevent adverse drug events associated with them.

Sonja Quale, Pharm.D., is the vice president and chief clinical officer at PharMerica Corporation.




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