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Jenna Merandi, Shelly Morvay, Dorcas Lewe, Barb Stewart, Char Catt, Phillip P. Chanthasene, Richard McClead, Karl Kappeler, Jay M. Mirtallo, Improvement of medication event interventions through use of an electronic database, American Journal of Health-System Pharmacy, Volume 70, Issue 19, 1 October 2013, Pages 1708–1714, https://doi.org/10.2146/ajhp130021
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Abstract
Patient safety enhancements achieved through the use of an electronic Web-based system for responding to adverse drug events (ADEs) are described.
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.
Implementation of a user-friendly electronic database improved intervention completion and documentation after medication event huddles.
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