Adverse drug reactions can have serious consequences.
Many of us became familiar with the impacts of adverse drug reactions when Vanessa’s Law regulations came into effect in 2019.
But one team in BC had already been studying them for years.
They considered the high number of reported adverse drug reactions that were likely preventable, along with their own observations, and decided to find out why these events were happening and how they could be prevented.
But the best news is that they’ve shared their research in a BMJ Open Quality article and given us the opportunity to share their story with you.
It all started back in 2014, when Jane de Lemos, a clinical pharmacy specialist at Richmond Hospital, noticed that patients were presenting at the emergency department (ED) with similar reactions to similar types of drugs.
She began reporting these events to Health Canada and studying them.
It wasn’t long before Jane recognized that certain types of reactions might be preventable and there would likely be value in studying them more formally.
She engaged a diverse team of physicians and pharmacists who were keen to help: Cheryl Nagle and Robert McKenzie, Family Practice; Yong Dong You, Peter Ling, and Anna Dabu, Internal Medicine; Richard Chan, ED; and Peter Loewen and Peter Zed from UBC’s Faculty of Pharmaceutical Sciences.
The team was awarded the VCH Research Institute Innovation and Translational Research Award, as well as funding from the Richmond Hospital Foundation and Richmond Hospital Physician Society to identify root causes and develop a surveillance and learning system for preventable adverse drug events (pADEs).
Jane de Lemos, Pharmacy, Richmond Hospital. Photo courtesy of Richmond Hospital Foundation.
Preventable adverse drug events
The study focused on pADEs, which refer to preventable harm resulting from taking or not taking a medication.
Wait…not taking a medication?
The team observed that certain symptoms could likely have been prevented with medication.
For instance, a patient experiencing heart failure may experience swelling. If the fluid goes into their lungs, they may experience shortness of breath and head to the ED. However, if the patient knows to weigh themself daily to check for increases in fluid, and if they were given an action plan recommending an extra diuretic and a call to their family physician, they could address this before the situation becomes serious.
Going to the source
To begin pinpointing root causes of pADEs, the team went straight to the source: patients and families.
The funding allowed the hiring of a research nurse to recruit and interview patients and families involved in 120 pADE cases causing admission.
The team also connected with patients’ family physicians, community pharmacists, and nurses to get their perspectives of the pADEs. The team’s multidisciplinary make-up allowed these interviews to be conducted peer-to-peer, with physicians interviewing physicians, pharmacists interviewing pharmacists, and nurses interviewing nurses.
“I’ve only heard of one other study that tried to interview both patients and providers and they had challenges getting interviews with providers”, says Jane. “We didn’t have that issue because we made it clear that this was a no-blame situation. We simply asked providers what they would have done differently from a quality improvement standpoint.”
Dr. Richard Chan, Richmond Hospital ED. Photo courtesy of Richmond Hospital Foundation.
Root causes and resources
After analyzing the patient and provider stories, patient data, and other related information, the team identified root causes for all the pADEs and key learning messages for some of the more common pADE-related admissions.
Not surprisingly, many of them were associated with communication.
“Providers need to ensure that patients understand how medications benefit their health,” says Jane. “If a patient doesn’t attach value to a medication, they may be less committed to taking it.”
Also, patients need to be able to recognize when a medication is causing a serious side effect or not working effectively.
They’ve also created an online learning module on Inhaler device coaching to help providers decrease their patients’ risk of hospitalization due to COPD or asthma flare-ups.
For a complete list of common presentations and root causes, download the Richmond Hospital preventable adverse drug event program handout.
To support ongoing surveillance of pADEs, the team partnered with IMITS to develop the Richmond Hospital pADE (RHpADE) tool.
The system reflects the team’s findings, enabling providers to report pADEs and select from a drop-down menu of root causes, such as ‘Did not have sick day medication plan’.
Letters are generated and sent to community providers as part of follow-up. The letters share the actions taken in the ED to address the root causes of the pADE and offer suggestions to prevent a similar event from recurring.
In future, the team hopes to engage a pharmacy student to help providers recognize common pADEs in the ED, identify root causes, and report them in the RHpADE tool.
This initiative has also resulted in system-wide improvements.
A drug-drug interaction (carvedilol–amiodarone) was identified as missing from the multisite hospital pharmacy drug interaction alert system. The team ensured this was flagged and corrected.
They also facilitated a change to the provincial private lab reporting system.
During their study, the team identified an ADE related to phenytoin and albumin levels. To help prevent the ADE from recurring, the lab report form was revised to include a reminder to provide a correction if the patient had low albumin, a link to a clinical calculator, and a 1-800 number to add albumin to the blood work if needed.
Reporting adverse drug events
When you identify an adverse drug event, Jane and the team encourage you to consider whether or not it was preventable. The resources developed by the RHpADE Program may be helpful to address root causes and reduce the patient’s risk of recurrence.
Providers across BC are encouraged to continue reporting adverse drug reactions in PSLS unless they report them in the RHpADE Tool (Richmond Hospital) and/or ActionADE (authorized VCH and PHC users only).
Both these tools share their data with the BCPSLS Central Office team, who ensure the data is reviewed, de-identified, and forwarded to Health Canada in compliance with Vanessa’s Law regulations.
Thanks to the team for their amazing work and to everyone who promotes patient safety by reporting adverse drug events in BC!
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