Baylor Health Care System ADE Trigger Tool Implementation Plan贝勒医疗体系使触发工具的实施计划.pptVIP

Targeted Injury Detection System for Adverse Drug Events: An AHRQ-Funded Patient Safety Initiative TIDS-ADE Background Trigger tool methodology ?focused mechanism for risk reduction ?event precipitates a response ?Example: IHI Adverse drug events ?common/costly ?usually actionable ?clinical/IT interface Project Goals Develop a functional trigger tool for ADEs in hospitalized patients that can be disseminated broadly Detection at multiple time points related to event occurrence (before, during, or after) Potential benefits in clinical care setting: 1. Prevention of ADEs 2. Mitigation of ongoing ADEs 3. Capture of “true” ADE rate Toolkit for real-world implementation Definitions Trigger = alert: any event prompting further investigation by clinician. ADE criteria = if event attributed to drug and: reaches a level of harm that is durable or requires a change in the treatment plan due to unacceptable level of risk for harm or patient discomfort Example of “unacceptable risk” for patient harm: -INR ≥ 6.0 and active warfarin order -event prompted discontinuation of drug=ADE Broader concept of ADEs Organizational Structure Implementation: Site Environments Site leader meetings Activation of IT/programming resources Project introduction to site staff Validation of triggers Launch 3-9 months prior to start 2-6 months prior to start 1-4 months prior to start 4-6 weeks prior to start Begin pilot Implementation: Triggers Choice/set-up of triggers: ?higher yield alerts (Classen, Evans JAMA 1991) ?core set of 15?20 consensus, tiered TIDS alerts ?tailoring to local site capabilities/priorities Trigger validation steps (3-phases): ?programmer’s bank of “dummy data” ?real-time pre-launch tests by site IT pharmacist ?post-launch troubleshooting for obvious “misses” Uniform process for evaluating trigger utility Results? Trigger Evaluation Trigger Evaluation Trigger Evaluation Trigger evaluation TIDS-ADE: