The Medical and Quality Team has developed a report from our rehab-skilled electronic medical record PointClickCare that uncovers potentially preventable adverse events caused by warfarin (Coumadin.)
This report uses the concept of a “Trigger Tool,” described by the Institute for Healthcare Improvement (IHI) as follows:
"The use of "triggers," or clues, to identify adverse events (AEs) is an effective method for measuring the overall level of harm from medical care in a health care organization. Traditional efforts to detect AEs have focused on voluntary reporting and tracking of errors.
However, public health researchers have established that only 10 to 20 percent of errors are ever reported and, of those, 90 to 95 percent cause no harm to patients. Health systems need a more effective way to identify events that do cause harm to patients, in order to select and test changes to reduce harm."
We started with warfarin because this medication is being raised as being of particularly high risk to residents at skilled nursing facilities. It requires frequent monitoring often accompanied by dosing changes and it interacts with many other medications, supplements, and foods.
When our trigger tool identifies a potential problem with warfarin, a clinical pharmacist review is performed. The purpose of this review is to determine whether the case represents a potentially preventable medication-related adverse event.
If this is determined, communication with the center requests a more in-depth review by nursing staff, medical staff, and consultant pharmacist.
If the case is confirmed as potentially preventable, steps are taken to ensure the safety of the resident involved while improving processes to reduce the chance of harm to future patients on warfarin.
Future work will expand the trigger tool to target additional medications, likely first expanding to high-risk areas such as diabetes and pain management.