Let's rethink Allergies and Adverse Drug Reactions
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The document discusses improving the recording and sharing of patient allergy and adverse drug reaction information across New Zealand's district health boards. It notes that current systems require manual entry of this information at each new location. The author argues that with tools like the National Health Index and ePrescribing systems, the necessary building blocks exist to develop a standardized way to collect, transfer and utilize patient allergy data nationally. The author calls for collaboration to pilot an improved solution in the Auckland region that could then be scaled nationwide.
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Let's rethink Allergies and Adverse Drug Reactions
- 1. Pharmacy Supporting the patient medication pathway to deliver the best outcomes Click to edit Master title style Let’s rethink Allergies and Adverse Drug Reactions Rob Ticehurst, Principal Pharmacist, Auckland DHB
- 2. Pharmacy Supporting the patient medication pathway to deliver the best outcomes
- 3. Pharmacy Supporting the patient medication pathway to deliver the best outcomes A Tragic Accident • Devastating for all involved – Family – Staff • We owe it to Eunice’s family to learn from this and change the system – it mustn’t happen again
- 4. Pharmacy Supporting the patient medication pathway to deliver the best outcomes NHI Medical Warning System
- 5. Pharmacy Supporting the patient medication pathway to deliver the best outcomes
- 6. Pharmacy Supporting the patient medication pathway to deliver the best outcomes
- 7. Pharmacy Supporting the patient medication pathway to deliver the best outcomes ePrescribing & Administration Implementation due in all DHBs by end of 2016 – Southern – Taranaki – Waitemata – Canterbury “It reduces the risk of errors, and alerts doctors to potential issues such as under- or over-prescribing, medicines that are contra-indicated and allergies.” NHIT Plan Update
- 8. Pharmacy Supporting the patient medication pathway to deliver the best outcomes alerts doctors to potential issues such as under- or over-prescribing, medicines that are contra-indicated and allergies
- 9. Pharmacy Supporting the patient medication pathway to deliver the best outcomes alerts doctors to potential issues such as under- or over-prescribing, medicines that are contra-indicated and allergies NHI Medical Warning System
- 10. Pharmacy Supporting the patient medication pathway to deliver the best outcomes Problem solved? No
- 11. Pharmacy Supporting the patient medication pathway to deliver the best outcomes Why not? MWS – medication field is free text ePA requires the manual entry of a patients allergy status
- 12. Pharmacy Supporting the patient medication pathway to deliver the best outcomes Done that – surely problem solved? Partially If a patient moves to a different DHB that allergy needs to be entered in the ePA system all over again
- 13. Pharmacy Supporting the patient medication pathway to deliver the best outcomes Are you serious? Houston, we have a problem. Thankfully we aren’t planning a trip to the moon. We need to collect, transfer and utilise around a dozen fields of information.
- 14. Pharmacy Supporting the patient medication pathway to deliver the best outcomes The building blocks are there…
- 15. Pharmacy Supporting the patient medication pathway to deliver the best outcomes The building blocks are there…
- 16. Pharmacy Supporting the patient medication pathway to deliver the best outcomes The building blocks are there…
- 17. Pharmacy Supporting the patient medication pathway to deliver the best outcomes The building blocks are there… NHI Medical Warning System
- 18. Pharmacy Supporting the patient medication pathway to deliver the best outcomes The building blocks are there… NHI Medical Warning System
- 19. Pharmacy Supporting the patient medication pathway to deliver the best outcomes The building blocks are there… NHI Medical Warning System
- 20. Pharmacy Supporting the patient medication pathway to deliver the best outcomes The building blocks are there… NHI Medical Warning System
- 21. Pharmacy Supporting the patient medication pathway to deliver the best outcomes The building blocks are there… NHI Medical Warning System
- 22. Pharmacy Supporting the patient medication pathway to deliver the best outcomes What next? • No more excuses – We owe it to Eunice and others before her • Within this room we have the skills, knowledge and power to address this issue • Learn from others – this is not just an NZ issue • Let’s collaborate and pilot something in the Auckland region that is scalable for National use • Showcase at the IHTSDO 2016 NZ meeting
- 23. Pharmacy Supporting the patient medication pathway to deliver the best outcomes Thank you • Northern Region Allergy & ADR group • NHITB • All of you
Editor's Notes
- No-one meant to do Eunice harm. Despite warnings being in place, processes still fell over and meant that Eunice was administered an antibiotic to which she had a known severe allergy and that contributed to her death. Unfortunately this is not an un-common event. Thankfully few have such a severe outcome – but the potential for significant harm remains. These incidents are entirely preventable.
- Eunice wore a medic alert bracelet warning of her allergy status. Her allergy had been notified to the Centre for Adverse Reaction Monitoring and as in the National Medical Warning system linked to her NHI. There was clear documentation on her paper medication chart, (Slide, slide) however events still conspired to enable Eunice to be given the medicine. This is illustrative of the difficulty of putting ‘hard stops’ to prevent this sort of incident occurring with a mix of paper and electronic systems.
- Eunice wore a medic alert bracelet warning of her allergy status. Her allergy had been notified to the Centre for Adverse Reaction Monitoring and there was clear documentation on her paper medication chart, however events still conspired to enable Eunice to be given the medicine. This is illustrative of the difficulty of putting ‘hard stops’ to prevent this sort of incident occurring with a mix of paper and electronic systems.
- Eunice wore a medic alert bracelet warning of her allergy status. Her allergy had been notified to the Centre for Adverse Reaction Monitoring and there was clear documentation on her paper medication chart, however events still conspired to enable Eunice to be given the medicine. This is illustrative of the difficulty of putting ‘hard stops’ to prevent this sort of incident occurring with a mix of paper and electronic systems.
- The latest update of the National Health IT Plan indicates that all DHBs should have electronic prescribing and administration in place by the end of 2016. 4 DHBs are already well into their implementation. Auckland DHB is next The same document states that ePA will reduce the risk of errors, and alert doctors to potential issues such as under- or over-prescribing, and the administration of medicines that are contra-indicated or that a patient has known allergies to.
- Let’s take another look at that - alerting users of the system to the presence of allergies - fantastic.
- So surely when we add in the detail held within existing electronic systems such as CARM and Medic Alert then tragic accidents like Eunice’s will never happen again.
- Problem solved? Unfortunately not.
- The medication field in the Medical Warning System is a freetext field. In one DHBs record system there are over 15 terms that have been used to describe a single medicine! It’s very difficult to run Clinical Decision Support against free text and therefore we require our clinicians to enter the data manually to enable the decision support to work.
- So once the allergy status has been manually entered in the system it works beautifully. No argument there! However, our patients do move between DHBs – particularly when they are very sick and therefore at their most vulnerable. This is particularly true in the Auckland Region. There is currently no ability to transfer data between hospitals running the same ePA system – nor is there any indication as to when this will be possible.
- Unfortunately yes. We do indeed have a problem. However, the reality is that we just need a system that will facilitate the collection, transfer and utilisation of a very small amount of data.
- Almost 40 years on from the introduction of the Medical Warning System we have some key enablers in place to help us to make a difference
- Fast Healthcare Interoperability Resources Emerging standards to help us transfer this information around.
- And we have some very smart people to help us join the dots
- Let’s break down the barriers. Let’s ensure we learn from others who are on this same journey – Spain, Denmark and other IHTSDO members
- NHITB for accepting the challenge YOU for ensuring this happens