Category: Professional Posters
Purpose: In an assessment to eliminate clinical variation, it was recognized by Ascension Pharmacy leadership that reporting of composite medication event data was not aligned from market to market. The Ascension National Medication Safety Team was charged with optimizing and standardizing medication event data reporting in 15 ministry markets and 151 hospitals across the United States.
The objective of this project was to plan and develop a secure cloud based interactive dashboard utilizing warehouse data from the voluntary event reporting system. The dashboard should be filterable and support the display of medication event graphics for Ascension, individual markets, and specific hospitals
Methods: The National Medication Safety Team utilized data collected from the standardized voluntary event reporting system for Ascension. Data is warehoused securely by the Ascension Healthcare Patient Safety Organization (AHPSO).
The team designed a pilot dashboard using a custom report from event data beginning October 1st to December 31st, 2018. After data optimization, the pilot dashboard was presented to leadership including the director of quality management and senior data analysts at Ascension Healthcare. A proposal to construct a new Medication Event Dashboard to be added to other AHPSO protected dashboards on the Tableau cloud-based system was approved for construction in March 2019.
In April a review of the data fields needed for the dashboard was completed and a build timeline was outlined with initial deliverables in late April 2019. After the medication safety and build teams closely collaborated to review the dashboard, final changes were made the middle of May and the final version was published to the AHPSO Tableau server on May 28th, 2019. After publication, education to targeted users was completed detailing optimal report utilization and methods for presentation to local therapeutic and medical staff committees.
Results: Upon publication of the Medication Events Dashboard, each pharmacy user has the ability to view graphics that illustrate medication related events. Dashboards included are: total medication events by volume; frequently occurring medications and classes; assessment by final severity; root causes of event (nature/subnature); contributing factors; and care process involved in event. Each of these six dashboards can be independently filtered to view and trend all Ascension, market level, and individual hospital level events. Filters are also available to select specific medications or classes for investigation as well as trending causes and/or near miss versus those events reaching patients.
The interactive dashboard uses a standardized data source and graphics to report medication events to committees across Ascension. Medication safety improvements through identification of frequently occurring event types and high-alert medication events have resulted in development of targeted performance improvement at both the national and local level. Work has continued by providing valuable positive feedback to care teams on actions taken toward patient safety as a result of voluntary reporting. The feedback is designed to encourage increases the voluntary event reporting culture in the future.
Conclusion: The successful development and publication of the Medication Events Dashboard has yielded an easily retrievable, cloud-based, interactive graphic representation of voluntarily reported medication events. The utilization of these dashboards has supported identification of trends and implementation of performance improvement to promote safe medication use across Ascension.