Laying the Foundation for Medication Safety Work
Contracted by the Centers for Medicare & Medicaid Services (CMs), atom Alliance began work to improve medication safety in 2015 with significant opportunities to partner with healthcare providers to improve patient care.
More than 29 percent of Medicare beneficiaries in atom Alliance states are at high risk for adverse drug events (ADEs), compared to 24 percent of Medicare beneficiaries nationwide. In addition, one in nine high-risk beneficiaries across the nation lives in an atom Alliance state—Alabama, Indiana, Kentucky, Mississippi or Tennessee.
The Solution to Improve Medication Safety
Quality Improvement Advisors at atom Alliance began addressing this growing problem by implementing a multicomponent educational program communicated through care coordination communities and the atom Alliance website. To design the program, they first consulted with experts in the field of medication safety, including pharmacists. Next, they developed an educational strategy based on the National Action Plan for Adverse Drug Event Prevention, the National Quality Strategy and other regional and national initiatives. They then developed a Medication Safety Starter Kit to provide the framework for providers to begin medication safety work. Finally, the kit formed the basis for an October 2015 webinar, “Tools to Improve Medication Safety” that included clarification of common medication safety terms and recommended a focused effort to improve safety for three high-risk medication classes: anticoagulants, antidiabetics and opioids. atom Alliance offered continuing education for pharmacists, resulting in more than 230 registrants.
The Challenges:
The multicomponent educational program was tailored to meet the challenges the team encountered in medication safety work and provide targeted education and resources to pharmacists and other providers. The first challenge was that most pharmacists are new to quality improvement and have limited knowledge of Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs), such as atom Alliance. Provider misconceptions about medication safety terminology and difficulties identifying a medication safety improvement focus were also challenges.
The Results:
Feedback on the educational program shows positive responses and results from providers:
“The simplicity to focus on three areas rather than all the medications being given will allow us to make an initial focus that is so much more reasonable!” – Hospital Chief Nursing Officer
“Medicare Part D Star Ratings are going to affect your reimbursement in the coming year. By working with atom on medication safety, we were able to increase our star rating. When we started out we were at 4 and now we’re at 4.7. So that’s made a world of difference in our star ratings because we are now tracking ADEs and we have a log.” – Community pharmacist
Lessons Learned:
As atom Alliance expands medication safety work in 2016, here are some lessons learned in 2015 that other healthcare providers might find beneficial:
- Pharmacy is new to quality improvement work. Providers in this setting require a thorough understanding of the work and what the QIN-QIO’s role is in quality improvement.
- There are misconceptions among providers about common medication safety terms, resulting in reduced identification of patient harm.
- Improving medication safety can seem overwhelming to providers, and a focused approach on high risk medication classes is necessary.
Join atom Alliance and healthcare providers in working collectively towards success in improving medication safety. Learn more here or contact Amanda Ryan, atom Alliance ADE Lead.
Download this infographic that outlines the plan and the challenges of improving medication safety in the atom Alliance states.
