The BWH Pharmacy Department Adverse Drug Event (ADE) Monitor Team received national recognition as the recipients of the Institute for Safe Medication Practice’s (ISMP) Cheers Award. The Cheers Award honors organizations that set a standard of excellence for the prevention of medication errors and adverse events.
The ADE Monitor program consists of computer software that acts as a search engine, simultaneously looking at medication orders and lab reports and cross-referencing them with guidelines, created by the ADE Monitor Team. The software then generates a report comprised of alerts that identify patients who are at risk for adverse drug events based on these rules.
“This program is truly unique in that it enables us to identify events before they occur,” said Tejal Gandhi, MD, MPH, director, Patient Safety. “We are approaching ADEs proactively as opposed to reactively, which is how we want BWH staff to think about patient safety issues overall.”
Pharmacists bring ADE reports on rounds, using them to perform more targeted chart reviews and to clinically assess whether an intervention with the physician is needed.
“The pharmacists are now more involved with direct patient care through the ADE Monitor program,” said Bill Churchill, MS, RPh, director, Pharmacy Services. “Physicians, nurses and pharmacists are working hand-in-hand to ensure quality patient care. This team-based approach has elicited a positive response from all staff, increasing job satisfaction among our pharmacists.”
“The success of the ADE Monitor program is due, in large part, to the partnership among physicians, nurses and pharmacists,” said Lina Matta, Pharm. D., Pharmacy Services. “Not only has it provided a tool to advocate patient safety, but it has also created a venue that fosters a collaboration providing optimal care.”
All alerts and interventions are entered into a database and tracked, allowing the ADE Monitor Team to review and analyze all data to gain a sense of what is and is not an ADE and further refine the guidelines based on that assessment.
“Right now the ADE Monitor Program gets us in the ballpark, relative to predicting which patients will be affected by ADEs,” said Carl Stapinski, RPh, medication safety officer. “This tool is able to scan thousands of medication and lab orders that would be impossible to otherwise review. As we further refine the alerts, based on physician, nurse, and pharmacist feedback, we are aiming to create even more predictive alerts, allowing the pharmacist to be more efficient at detecting a potential adverse event.”
Once the planned electronic Medication Administration Record (MAR) is functional here at BWH, the ADE Monitor Team will work with IS to link the ADE Monitor to it, allowing pharmacists to screen for potential ADE’s based on medications actually administered, instead of scanning for medications ordered, but not necessarily given. A more effective patient safety tool will be the result.
The ISMP Cheers Award will be presented at the 2002 midyear clinical meeting of the American Society of Health System Pharmacists. It is the first Cheers Award BWH has received.