Problem Addressed

• Serious implications of poor health literacy: When patients do not understand health information, their care may be compromised with increased risk for medical errors that can have tragic results.¹
• A common problem with serious consequences: An estimated 770,000 hospitalized Americans experience adverse drug reactions each year, costing up to $5.6 billion.² A metaanalysis found that fatal reactions in the hospital are among the top six causes of death.³ More than one-third of preventable adverse drug events in hospitals occur under a nurse's supervision, with many of these occurring during the administration of medications.⁴
• Obstacles to accurate reporting: Several factors reduce the accuracy of hospital records on allergies and adverse drug reactions, including:
  • Lack of patient awareness: Patients often lack awareness of their allergies and previous adverse reactions, especially if they take multiple medications. Patients may assume side effects of a medication are normal, mistakenly believe their physician is already aware of their history, not know how to report such information to their physicians and other health professionals, and/or fail to recognize the importance of doing so.⁵
  • Low reporting rate by nurses: Although nurses routinely administer medications and witness adverse drug reactions, they often fail to identify or report them, due primarily to a lack of time and/or the mistaken assumption that another staff member will report the event. At West Los Angeles Healthcare Center, only 1 percent of reported adverse drug reactions came from nurses (compared with 35 percent from physicians, 37 percent from pharmacists, and 27 percent from physician assistants and nurse practitioners).⁴
  • Ineffective record keeping: Even when patients or nurses report adverse drug reactions, the information does not always follow the patient due to human error and/or ineffective record keeping. For example, records sometimes are not forwarded when patients move to different states or change doctors, and information recorded during an emergency department visit may not be entered into the patient's health record. Even when information is entered into that record, drug names are sometimes misspelled. At West Los Angeles Healthcare Center, a retrospective chart review found that 20 to 50 percent of patients had a medication allergy that had not been properly documented.⁴

Description of the Innovative Activity

• Improving health literacy: The hospital partnered with The Joint Commission's Speak Up™ campaign to encourage patients to report medication allergies and adverse drug reactions and to ask their providers questions about their prescriptions. Nurses and pharmacists throughout the hospital teach patients about the importance of informing their providers about their medication allergies. West Los Angeles Healthcare Center also distributes educational brochures describing the importance of the patient role in medication safety and encouraging patients to be active participants in medical care by requesting information about their medication and treatment.
• Patient allergy reconciliation: The hospital created a one-page form in which patients document any allergies they might have to medication, food, and other items such as herbs, tape, dye, or latex. Patients with allergies are also asked to describe their symptoms. The form includes space for staff to document patient allergies have been updated in the hospital's electronic medical record (EMR) system. Distribution and collection of allergy forms is reinforced by staff members who have a special interest in the program, including a pharmacist and a case manager.
• Initial and ongoing nurse education: When the program debuted in 2005, all West Los Angeles Healthcare Center nurses attended a 1-hour presentation that covered the following: procedures to improve medication safety, accurate reporting and entry of allergies/adverse drug reactions into the hospital's EMR, and typical errors that occur during EMR entry (e.g., incorrect spelling of the names of medications). Nurses also received a fact sheet summarizing this material. This module has now been incorporated into the orientation of new nurses and made a part of all nurses' ongoing training.

References/Related Articles

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Innovator Disclosures

Results

• Increased awareness and reporting by nurses: During a 7-month study before and after the program was rolled out, the number of adverse drug reactions reported each month by nurses rose from 3 to 48. In 2007, the average number of nurse-reported events represented approximately 8 percent of the hospital's total reported adverse drug reactions compared with less than 1 percent before the program began.
• Medication allergy reconciliation: Since West Los Angeles Healthcare Center instituted the medication allergy questionnaire, patients have reported approximately 30 percent more medication allergies than what was previously documented in their medical record. When nursing staff compared the completed questionnaires with the EMR, they were able to identify inconsistencies between the EMR and the questionnaire and reconcile the information. In addition to verifying if the medication allergy information in the EMR was accurate, nurses found that this was a valuable opportunity for the nurses to remind patients/families of the medication allergies (10 to 15 percent of patients completing the questionnaire failed to list all of their medication allergies that were accurately documented in the EMR).

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Program initiation and team formation: In late 2004, three senior nurses (the assistant chief nurse, a case manager, and a clinical specialist in informatics) began researching and developing the program. Six other staff members volunteered to help, forming a team that met once or twice a week over the next several months.
• Creation of program elements: The team's literature review of best practices identified an educational project run by the pharmacy at the Veterans Administration New York Harbor Healthcare System that focused on teaching patients about recognizing and reporting adverse drug reactions. The team adapted the educational brochures used in New York for use at West Los Angeles Healthcare Center, developed the 1-hour training module for nurses, and created the patient questionnaire.
• Training: Current nursing staff took the 1-hour training module over a period of several weeks; this module was also incorporated into the formal orientation program for newly hired nurses.
• Program rollout: The program was implemented in February 2005. Initially, primary care clinic nurses agreed to distribute and collect the patient questionnaires and hand out the brochures. However, after noticing that the return rate for the questionnaire was low, the team expanded the sites for distribution and collection to include one inpatient unit, several outpatient clinics, and the pharmacy (which is the single largest source for completed questionnaires).

Resources Used and Skills Needed

• Staffing: The program did not require hiring additional staff, as the development team and all nurses participate as part of their regular duties. Early on, the program was helped significantly by a senior nursing student who volunteered to enter questionnaire data into patients' EMRs and update them accordingly.
• Costs: Costs associated with the program are minimal, consisting primarily of copying costs for the brochures, questionnaires, and other educational materials.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Reach patients through multiple sites: More patients will respond to questionnaires and read educational brochures if they are distributed at multiple locations. The pharmacy provides an ideal venue, because patients waiting for prescriptions are likely to be focused on the issue of medications and have time to fill out the questionnaire and read brochures.
• Build in time to reconcile patient records with their memories: Recognize that gathering accurate data on allergies and adverse drug reactions will inevitably reveal lapses in existing records and patient memories (i.e., patient records may be inaccurate and need to be corrected, whereas patients may need to be reminded of past adverse reactions or current allergies that they have forgotten). To address this issue, develop a systematic approach to ensuring an accurate record, such as checking with patients' families and prior caregivers if necessary. In addition, set aside time to remind patients of their medication allergy and adverse drug reaction history.

Sustaining This Innovation

• Institutionalize adverse drug reaction awareness: For hospital staff, this process includes making the module a part of the orientation process for new nurses and routinely reviewing key points from the module as a part of ongoing training of existing nurses. For patients, this process means making sure that an adequate supply of brochures and questionnaires is always available and that nursing and pharmacy staff remain diligent about asking patients to read the brochure and fill out the questionnaire.

Additional Considerations and Lessons

• The hospital won the 2007 Veterans Affairs Office of Nursing Services Innovation Award for this project.