SummaryThe West Los Angeles Healthcare Center, a Veterans Affairs hospital, implemented a program to enhance the reporting of medication allergies by improving patients' health literacy and nurses' knowledge about signs and symptoms of medication allergies and adverse drug reactions. The center partnered with The Joint Commission's Speak Up™ campaign to encourage patient partnering with providers to improve health care safety. The program has led to increased awareness and reporting of allergies and adverse drug reactions by nurses and patients, which enabled the hospital to improve medication allergy reconciliation between patients and their electronic medical records and has led to anecdotal reports of prevention of adverse drug reactions.Moderate: The evidence consists of pre- and post-implementation data on nurses' adverse drug reaction reporting, post-implementation data on patient reporting of adverse drug reactions and allergies, and anecdotal reports.
Developing OrganizationsWest Los Angeles Healthcare Center
Date First Implemented2005
Problem AddressedAdverse drug reactions are a common problem that have a severe negative impact on the quality of inpatient care. Although accurate reporting of existing medication allergies and previous events by nurses and patients may prevent future adverse drug reactions, a number of obstacles to such reporting exist.
- 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 ActivityWest Los Angeles Healthcare Center created a program to increase patient and nurse reporting of medication allergies and adverse drug reactions. Each component is described in more detail below:
- 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.
Context of the InnovationWest Los Angeles Healthcare Center provides inpatient, primary, tertiary, and ambulatory care to veterans living in Los Angeles County. The center's facilities include a 296-bed hospital and three 120-bed nursing home units. The program was prompted by nurse leaders who were interested in improving medication safety; these leaders noticed that relatively few nurses routinely reported adverse drug reactions and that many patients did not know the importance of reporting medication allergies and adverse reactions to their providers. These leaders believed that a nurse-centered program that included other hospital staff (e.g., pharmacists and information specialists) could address these problems and thus enhance patient safety.
ResultsThe program led to increased awareness and reporting of adverse drug reactions by nurses and patients, which enabled the hospital to improve the accuracy of its EMR and has led to anecdotal reports of adverse events being prevented.
Moderate: The evidence consists of pre- and post-implementation data on nurses' adverse drug reaction reporting, post-implementation data on patient reporting of adverse drug reactions and allergies, and anecdotal reports.
- 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. To assist in this, pharmacy data was used to identify adverse drug reactions and to track if staff had reported the reaction; this specific data also demonstrated an increase in nurse reporting from the baseline. 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).
Planning and Development ProcessKey steps in the planning and development process included the following:
- 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 SourcesThe program is covered by West Los Angeles Healthcare Center's internal operating budget.
Tools and Other ResourcesFor more information about The Joint Commission's Speak Up™ Campaign, visit http://www.jointcommission.org/speakup.aspx.
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 InnovationInstitutionalize 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.
Contact the InnovatorSharon Valente, RN, PhD, FAAN
Associate Chief Nurse, Research and Education
Greater Los Angeles Healthcare System
11301 Wilshire Blvd., Bldg. 500
Los Angeles, CA 90073
Innovator DisclosuresDr. Valente has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
RecognitionIn 2007, Dr. Sharon Valente and the Greater Los Angeles Healthcare System won the Veterans Affairs Office of Nursing Services Innovation Award for work on this project. This award recognizes nursing leadership in quality improvement. More information is available at: http://www.va.gov/NURSING/nationalawards.asp.
References/Related ArticlesValente S, Murray L, Fisher D. Nurses improve medication safety with medication allergy and adverse drug reports. J Nurs Care Qual. 2007;22(4):322-7. [PubMed]
Wilson JF. The crucial link between literacy and health. Ann Intern Med. 2003;139(10):875-8. [PubMed]
2 Committee on the Work Environment for Nurses and Patient Safety. Keeping patients safe: transforming the work environment of nurses. Institute of Medicine, 2004.
Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998 Apr 15;279(15):1200-5. [PubMed]
Valente S, Murray L, Fisher D. Nurses improve medication safety with medication allergy and adverse drug reports. J Nurs Care Qual. 2007;22(4):322-7. [PubMed]
Oermann MH, Templin T. Important attributes of quality health care: consumer perspectives. J Nurs Scholarsh. 2000;32(2):167-72. [PubMed]
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Original publication: February 02, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: January 28, 2014.
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