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Authors

Hillary J. Mull, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System; Department of Surgery, Boston University School of MedicineFollow
Amy K. Rosen, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System; Department of Surgery, Boston University School of MedicineFollow
Stephanie L. Shimada, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital; Department of Quantitative Health Sciences, University of Massachusetts Medical School; Boston University School of Public Health
Peter E. Rivard, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System; Sawyer Business School, Suffolk University
Brian Nordberg, Health Catalyst
Brenna Long, Geriatrics Research Education and Clinical Center, VA Salt Lake City Health Care System; University of Utah
Jennifer M. Hoffman, Geriatrics Research Education and Clinical Center, VA Salt Lake City Health Care System; University of Utah
Molly Leecaster, Geriatrics Research Education and Clinical Center, VA Salt Lake City Health Care System; University of Utah
Lucy A. Savitz, University of Utah; Intermountain Healthcare
Christopher W. Shanahan, Boston University School of Medicine; Boston Medical Center
Amy Helwig, Office of the National Coordinator for Health IT
Jonathan R. Nebeker, Geriatrics Research Education and Clinical Center, VA Salt Lake City Health Care System; University of Utah

Submission Type

Empirical Research

Keywords

adverse drug events; trigger tools; outpatient care; patient safety

Abstract

Background: Adverse drug event (ADE) detection is an important priority for patient safety research. Trigger tools have been developed to help identify ADEs. In previous work we developed seven concurrent, action-oriented, electronic trigger algorithms designed to prompt clinicians to address ADEs in outpatient care.

Objectives: We assessed the potential adoption and usefulness of the seven triggers by testing the positive predictive validity and obtaining stakeholder input.

Methods: We adapted ADE triggers, “bone marrow toxin - white blood cell count (BMT‑WBC),” “bone marrow toxin - platelet (BMT-platelet),” “potassium raisers,” “potassium reducers,” “creatinine,” “warfarin,” and “sedative hypnotics,” with logic to suppress flagging events with evidence of clinical intervention and applied the triggers to 50,145 patients from three large health care systems. Four pharmacists assessed trigger positive predictive value (PPV) with respect to ADE detection (conservatively excluding ADEs occurring during clinically appropriate care) and clinical usefulness (i.e., whether the trigger alert could change care to prevent harm). We measured agreement between raters using the free kappa and assessed positive PPV for the trigger’s detection of harm, clinical usefulness, and both. Stakeholders from the participating health care systems rated the likelihood of trigger adoption and the perceived ease of implementation.

Findings: Agreement between pharmacist raters was moderately high for each ADE trigger (kappa free > 0.60). Trigger PPVs for harm ranged from 0 (Creatinine, BMT-WBC) to 17 percent (potassium raisers), while PPV for care change ranged from 0 (WBC) to 60 percent (Creatinine). Fifteen stakeholders rated the triggers. Our assessment identified five of the seven triggers as good candidates for implementation: Creatinine, BMT-Platelet, Potassium Raisers, Potassium Reducers, and Warfarin.

Conclusions: At least five outpatient ADE triggers performed well and merit further evaluation in outpatient clinical care. When used in real time, these triggers may promote care changes to ameliorate patient harm.

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

DOI

10.13063/2327-9214.1116

Appendix 1.docx (15 kB)
Appendix 1: Evolution of Outpatient ADE Trigger Logic Prior to Implementation

Appendix 2.docx (59 kB)
Appendix 2: Chart Review Tool

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