Developing a patient safety surveillance system to identify adverse events in the intensive care unit

Critical Care Medicine

Volumn 38, Issue 6 SUPPL., 2010, Pages

  Stockwell, David C ^a   Kane Gill, Sandra L ^b,c  

^a GEORGE WASHINGTON UNIVERSITY SCHOOL OF MEDICINE AND HEALTH SCIENCES   (United States)

^b UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE   (United States)

^c UNIVERSITY OF PITTSBURGH MEDICAL CENTER   (United States)

Author keywords

Adverse event; Electronic health record; Incident report; Intensive care units; Medical error; Patient safety; Rigger tool

Indexed keywords

DIPHENHYDRAMINE; GLUCOSE; METHYLPREDNISOLONE; PHYTOMENADIONE; POLYSTYRENE; PROTAMINE; VACCINE;

ADVERSE DRUG REACTION; DATA COLLECTION METHOD; HUMAN; INTENSIVE CARE UNIT; MEDICAL RECORD REVIEW; OBSERVATIONAL METHOD; PATIENT SAFETY; PRIORITY JOURNAL; REVIEW; TOTAL QUALITY MANAGEMENT; VOLUNTARY REPORTING;

EID: 77953048972     PISSN: 00903493     EISSN: 15300293     Source Type: Journal    
DOI: 10.1097/CCM.0b013e3181dde2d9     Document Type: Article

References (68)

1. National Academy for State Health Policy, Patient Safety Toolbox for States. Available at http://www.nashp.org/pst-welcome. Accessed April 14, 2010
2. Agency for Healthcare Research and Quality, Patient Safety Organizations Home Page. Available at http://www.pso.ahrq.gov. Accessed October 20, 2009
3. University HealthSystem Consortium. Available at https://www.uhc.edu/ 12443.htm. Accessed October 20, 2009
4. MEDMARX Main Page. Available at https://www.medmarx.com/. Accessed October 20, 2009
5. U.S. Food and Drug Administration: Reports received and reports entered into AERS by year. Available at http://www.fda.gov/Drugs/ GuidanceComplianceRegulatoryInformation/ Surveillance/AdverseDrugEffects/ ucm070434. htm. Accessed October 20, 2009
6. U.S. Food and Drug Administration: MedWatch: The FDA safety information and adverse event reporting program. Available at http://www.fda.gov/Safety/ MedWatch/default. htm. Accessed October 20, 2009
7. U.S. Food and Drug Administration: Blood & blood products. Available at http://www.fda.gov/BiologicsBloodVaccines/BloodBloodProducts/default.htm. Accessed October 20, 2009
8. About medical event reporting system for transfusion medicine (MERS-TM). Available at http://www.mers-tm.org/about.html. Accessed October 20, 2009
9. Classen DC, Pestornik SL, Evans RS, et al: Computerized surveillance of adverse drug events in hospital patients. JAMA 1991; 266: 2847-2851
10. Jha AK, Kuperman GJ, Teich JM, et al: Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 1998; 5:305-314
11. Flynn EA, Barker KN, Peppper GA, et al: Comparison of methods for detecting medication errors in 36 hospitals and skillednursing facilities. Am J Health Syst Pharm 2002; 59:436-446
12. Lisby M, Nielsen LP, Mainz J: Errors in the medication process: Frequency, type and potential. Int J Qual Health Care 2005; 17: 15-22
13. Buckley MS, Erstad BL, Kopp BJ, et al: Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. Pediatr Crit Care Med 2007; 8:145-152
14. Sharek PJ, Horbar JD, Mason W, et al: Adverse events in the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICU. Pediatrics 2006; 118:1332-1340
15. Olsen S, Neale G, Schwab K, et al: Hospital staff should use more than one method to detect potential adverse events: Incident reporting, pharmacist surveillance and local real-time record review may all have a place. Qual Saf Health Care 2007; 16:40-44
16. Ferranti J, Harvath MM, Cozart H, et al: Reevaluating the safety profile of pediatrics: A comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment. Pediatrics 2008; 121:e1201-e1207
17. Takata GS, Manson W, Taketomo C, et al: Development, testing and findings of a pediatric focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics 2008; 121:e927-e935
18. Franklin BD, Birch S, Savage I, et al: Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions. Pharmacoepidemiol Drug Saf 2009; 18:992-999
19. Kilbridge PM, Noirot LA, Reichley RM, et al: Computerized surveillance for adverse drug events in a pediatric hospital. J Am Med Inform Assoc 2009; 16:607-612
20. Nassens JM, Campbell CR, Huddleston JM, et al: A comparison of hospital adverse events identified by three widely used detection methods. Int J Qual Health Care 2009; 21: 301-307
21. Brvar M, Fokter N, Bunc M, et al: The frequency of adverse drug reaction related admissions according to method of detection, admission urgency and medical department specialty. BMC Clin Pharmacol 2009; 9:8
22. Kane-Gill SL, Bellamy CJ, Verrico MM, et al: Evaluating the positive predictive values of antidote signals to detect potential adverse drug reactions (ADRs) in the medical intensive care unit (ICU). Pharmacoepidemiol Drug Saf 2009; 18:1185-1191
23. Hurdle JH, Weir CR, Roth B, et al: Critical gaps in the world's largest electronic medical record: Ad hoc nursing narratives and invisible adverse drug events. AMIA 2003 Symposium Proceedings 2003; 309-312
24. Tam KW, Kwok KH, Fan KE, et al: Detection and prevention of medication misadventures in general practices. Int J Qual Health Care 2008; 20:192-199
25. Masheter CJ, Hougland P, Xu W: Advances in Patient Safety: From Research to Implementation. Volume 1: Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD9CM Code Classifications. Available at http://www.ahrq.gov/QUAL/advances. Accessed October 20, 2009
26. Hougland P, Xu W, Pickard S, et al: Performance of International Classification of Diseases, 9th Revision. Clinical modification codes as an adverse drug event surveillance system. Med Care 2006; 44:e629-e636
27. Nebeker JR, Yarnold PR, Soltysik RC, et al: Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. Med Care 2007; 10: S81-S88
28. Curtis JR, Chen H, Delzelll E, et al: Adaptation of Bayesian data mining algorithms to longitudinal claims data. Med Care 2008; 46: 969-975
29. Leonard CE, Haynes K, Localio AR, et al: Diagnostic E-codes for commonly used, narrow therapeutic index medications poorly predict adverse drug events. J Clin Epidemiol 2008; 61:561-571
30. Strom BL: Data validity issues in using claims data. Pharmacoepidemiol Drug Saf 2001; 10:389-392
31. Forster AJ, Andrade J, van Malraven C: Validation of a discharge summary term search method to detect adverse events. JAmMed Inform Assoc 2005; 12:200-206
32. Cullen DJ, Sweitzer BJ, Bates DW, et al: Preventable adverse drug events in hospitalized patients: A comparative study of intensive care and general care units. Crit Care Med 1997; 25:1289-1297
33. Kane-Gill SL, Kowiatek JG, Weber RJ: A comparison of voluntarily reported medication errors in intensive care and general care units. Qual Saf Health Care 2010; 19:55-59
34. AHRQ, WebM&M: Morbidity and Mortality Rounds on the Web. Available at http://www.webmm.ahrq.gov. Accessed October 20, 2009
35. Stockwell DC, Slonim AD: Overcoming organizational barriers Collecting: Error reporting systems. In: Pediatric Informatics: Computer Applications in Child Health. Lehmann CU, Kim GR, Johnson KB (Eds). New York, Springer Science+Business Media, 2009
36. Karson AS, Bates DW: Screening for adverse events. J Eval Clin Pract 1999; 5:23-32
37. Iyengar Q, Baxter A, Forster AJ: Using medical emergency teams to detect preventable adverse events. Crit Care 2009; 13:R126
38. Lipshutz AK, Morlock LL, Shore AD, et al: Medication errors associated with code situations in U.S. hospitals: Direct and collateral damage. Jt Comm J Qual Patient Saf 2008; 34:46-56
39. Melton GB, Hripsak G: Automated detection of adverse events using natural language processing of discharge summaries. JAmMed Inform Assoc 2005; 12:448-457
40. Cohen AM, Hersh WR: A survey of current work in biomedical text mining. Brief Bioinform 2005; 6:57-71
41. Murff HJ, Forster AJ, Peterson JF, et al: Electronically screening discharge summaries for adverse medical events. J Am Med Inform Assoc 2003; 10:339-350
42. Cantor MN, Feldman HJ, Triola MM: Using trigger phrases to detect adverse drug reactions in ambulatory care notes. Qual Saf Health Care 2007; 16:132-134
43. Rozich JD, Haraden CR, Resar RK: Adverse drug event trigger tool: A practical methodology for measuring medication related harm. Qual Safe Health Care 2003; 12: 194-200
44. Handler SM, Altman RL, Perera S, et al: A systematic review of the performance characteristics of clinical event monitor signals used to detect adverse drug events in the hospital setting. J Am Med Inform Assoc 2007; 14:451-458
45. Hwang SH, Sukhyang L, Koo HK, et al: Evaluation of a computer-based adverse-drugevent monitor. Am J Health Syst Pharm 2008; 65:2265-2272
46. Larsen GY, Donaldson AE, Parker HB, et al: Preventable harm occurring to critically ill children. Pediatr Crit Care Med 2007; 8:331-336
47. Ferranti J, Horvath M, Cozart H, et al: A multifaceted approach to safety: The synergistic detection of adverse drug events in adult inpatients. J Patient Saf 2008; 4:184-190
48. Levy M, Azaz-Livshits T, Sadan B, et al: Computerized surveillence of adverse drug reactions in hospital: Implementation. Eur J Clin Pharmcol 1999; 54:887-892
49. Kane-Gill SL, Visweswaran S, et al: Computerized detection of adverse drug reactions in the medical ICU. Abstr. Crit Care Med 2008; 36:A20
50. Stockwell DC, Muething SE, Chehab M, et al: Identifying adverse events electronically: Utilizing triggers across institutions. Abstr. Pediatric Academic Societies E-PAS 2008; 4845
51. Romero AV, Malone DC: Accuracy of adversedrug-event reports collected using an automated dispensing machine. Am J Health Syst Pharm 2005; 62:1375-1380
52. Rizos A, Snyder R, Rothschild JM, et al: Multi-method approach for medication safety event detection in community hospitals. AMIA Symposium Proceedings 2005:1096
53. Kowiatek JG, Weber RJ, Skledar SJ, et al: Assessing and monitoring override medications in automated dispensing devices. Jt Comm J Qual Patient Saf 2006; 32:309-317
54. Phansalkar S, Haffman JM, Nebeker JR, et al: Pharmacists versus nonpharmacists in adverse drug event detection: A meta-analysis and systematic review. Am J Health Syst Pharm 2007; 64:842-849
55. Kane-Gill SL, Devlin JW: Adverse drug event reporting in the intensive care unit: A survey of current practices. Ann Pharmacother 2006; 40:1267-1273
56. Beckman U, Bohringer C, Carless R, et al: Evaluation of two methods for quality improvement in intensive care: Facilitated incident monitoring and retrospective medical chart review. Crit Care Med 2003; 31: 1006-1011
57. Troutman WG, Doherty KM: Comparison of voluntary adverse drug reaction reports and corresponding medical records. Am J Health Syst Pharm 2003; 60:572-575
58. Schectman JM, Plews-Ogan ML: Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Pt Safety 2006; 32:337-343
59. Ulanimo VM, O'Leary-Kelley C, Connolly PM: Nurses' perceptions of causes of medication errors and barriers to reporting. J Nurs Care Qual 2007; 22:28-33
60. Stockwell DC, Slonim AD: Quality and safety in critical care units. Intensive Care Med 2006; 21:199-210
61. Frey B, Buettiker V, Hug MI, et al: Does critical incident reporting contribute to medication error prevention? Eur J Pediatr 2002; 161:594-599
62. Ricci M, Goldman AP, de Leval MR, et al: Pitfalls of adverse event reporting in paediatric cardiac intensive care. Arch Dis Child 2004; 89:856-859
63. Jarernsiripornkul N, Krska J, Capps PAG, et al: Patient reporting of potential adverse drug reactions: A methodological study. Br J Clin Pharmacol 2002; 53:318-325
64. Gandhi TK, Seger DL, Bates DW: Identifying drug safety issues: from research to practice. Int J Qual Health Care 2000; 12: 69-76
65. Leape LL, Cullen DJ, Clapp MD, et al: Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999; 282:267-270
66. Kucukarslan SN, Peters M, Mlynarek M, et al: Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med 2003; 163:2014-2018
67. Nissen L: Current status of pharmacist influences on prescribing of medicines. Am J Health Syst Pharm 2009; 66:s29-s34
68. Scarsi KK, Fotis MA, Noskin GA: Pharmacist participation in medical rounds reduces medication errors. Am J Health Syst Pharm 2002; 59:2089-2092