Why We Measure:
Adverse drug events can have a negative effect on a patient’s recovery. Measuring and improving our performance related to ADEs is part of providing a safe healing environment at Nationwide Children's Hospital. We use the information to focus our efforts on reducing the number of ADEs to the lowest number possible. We concentrate on providing the right medication, to the right patient, at the right time.
How We Measure:
Reporting Adverse Drug Events is voluntary. The reporting is done in an electronic Event Reporting System, referred to as ERS, that is available to all employees at the hospital. While most ADEs are reported through this system, some are found by tracking the use of medications that are only used to reverse the side effects of medications given by mistake. All ADEs are placed on a nine-point clinical severity scale depending on the seriousness of the error. The rate of error is measured as a ratio of the number of ADEs per 1000 doses of all medicine administered in the hospital.
How Are We Improving:
ADEs are reported daily, measured quarterly and reviewed by groups from many areas of the hospital. That information is then used to improve our performance. Our improvement efforts have led to the implementation of a Computerized Prescriber Order Entry, referred to as CPOE, system that has reduced errors caused by hard-to-read hand writing or arithmetic errors in calculating the dose of medicine. Further, hospital policy requires a pharmacist to review medication before the nurse takes it to the patient. Staff members are required to double-check high-risk medications before they are given to patients.
Some medications are more frequently involved in errors than others. Medications of this type are further studied by a group of hospital employees called “The Medication Safety Champions”. They attempt to find the reason for the frequent errors and develop a strategy to correct the problem. The group then teaches other staff members how to prevent similar errors in the future.
How We Measure?