Abstract 163: Decreasing Adverse Drug Events Through a "Simple Intervention"

Abstract

BACKGROUND: Patients in the cardiac intensive care unit (CICU) are at risk for adverse drug events (ADE). CICU ADEs may result in life-threatening consequences and have been shown to be associated with polypharmacy, severity of illness, and intensity of treatment. The purpose of this review was to highlight the significance of a multidisciplinary huddle following each ADE in reducing future events. METHODS: All patients admitted to the CICU at Nationwide Children’s Hospital from 2010 to 2012 were retrospectively reviewed. ADE reporting is voluntary via an electronic Event Reporting System. ADEs are placed on a 9 point clinical severity scale based on the seriousness of the error. Huddles, defined as an in depth multidisciplinary discussions revolving around causative factors and potential interventions, were instituted following harm-causing ADEs (clinical severity 4-9) and select high risk non-harming ADEs (clinical severity 1-3). ADEs were tracked, and the resultant huddles were reviewed. Huddle contributors included physicians, nurses, nurse practitioners, and pharmacists. Huddle process included chart review of events leading to the ADE, caregiver input about contributing clinical or situational factors, root cause identification, and prevention strategies. RESULTS: There were 238 ADEs (clinical severity 1-9); 60 huddles were conducted on ADEs of all severities. Causative factors identified were errors in drug administration (N=40), nursing stressors (N=21), nursing double check (N=17), human factors (N=16), handoffs (N=13), staffing (N=9), equipment (N=5), verbal orders (N=3), pharmacy (N=2), and medication reconciliation (N=1). Action plans initiated included extending the “distraction free zone”, improving nursing handoffs, implementing a hands-free communication system, improving the electronic medical record, educating and reinforcing unit policies, and eliminating verbal orders. Harm-causing ADEs were reduced from 0.43 to 0.06 per 1000 doses administered (p<0.0001). CONCLUSION: Multidisciplinary huddles are one effective tool utilized to spearhead a quality improvement initiative to reduce ADEs in a CICU. Huddles are analogous to a small-scale root cause analysis with the goal to determine causative factors and develop interventions to prevent future events.