Adverse Drug Reaction - Health Care Conference Administrators：药物不良反应的医疗会议管理员.ppt

Use of Automated Medication Dispensing Technology (Pyxis?) to Help Identify Trigger Medications and Concurrent Adverse Drug Events The Quality Colloquium August 21, 2006 Presented by Lori Edell, PharmD Diane Pascu, RPh, MBA Virtua Health Four Hospital System in Southern New Jersey Two Long Term Care Facilities Two Home Health Agencies Two Free Standing Surgical Centers Ambulatory Care – Camden Fitness Center 8000 employees and 2000 Physicians 7,500 infant deliveries $650 million in revenues STAR Culture Adverse Events Adverse events in the healthcare setting are often called incidents. Incidents may include both non-medication related events and medication related events. The Pharmacist The focus of the Pharmacist is on the medication related adverse events. Identification Improvement Process Knowledge base Prevention Adverse Drug Events Significant problem facing all hospitals Only 10-20 percent of errors are reported. The Institute for Healthcare Improvement (IHI) has established “trigger tools” for measuring ADEs (identifies patients retrospectively). Utilizing automated technology in conjunction with Nursing and Pharmacy identifies potential ADEs in a concurrent fashion.* * Institute for Healthcare Improvement, 2004. Definitions of Medication Safety terms Confusion exists over correct terminology. No universally accepted definition for “adverse drug reaction.” * Each institution establishes their own standards. Adverse Drug Events include medications errors (preventable by definition) and adverse drug reactions (not preventable by definition). * Qual Safe Health Care, 2005; 14: 358-363. Accepted Definitions Adverse reaction: In pharmacology, any unexpected or dangerous reaction to a drug. An unwanted effect caused by the administration of a drug. The onset of the adverse reaction may be sudden or develop over time. * Adverse event: In pharmacology, any unexpected or dangerous reaction to a drug.* No definition was listed for either adver