catalysts center for medication safety advancement annual report 2012-13 college of pharmacy
the inventory 0 2 Far-Reaching Remedies Craig K. Svensson, PharmD, PhD, Dean, College of Pharmacy 0 4 Salient Solutions Kyle E. Hultgren, PharmD, Director, Center for Medication Safety Advancement 0 6 Dispensing Teamwork Catherine R. Scott, CPHQ, Education Program Manager, Center for Medication Safety Advancement 0 8 Culture of Continuing Education Marlene O. Heeg, Managing Director, Office of Continuing Education and Professional Development, College of Pharmacy 10 Cures for Kenya Celia Chema Ngetich, International Medication Safety Fellowship Recipient, Moi Teaching and Referral Hospital, Eldoret, Kenya 12 Dose of Discovery Jaclyn A. Jeffries, PharmD, Medication Safety Resident, Center for Medication Safety Advancement 14 Active Ingredients Elizabeth Gill, Rebecca Schoen, Jessica Smith, Undergraduate Research Students 16 Side-by-Side Effects Betsy Lee, BSN, MSPH, Director, Indiana Patient Safety Center, Indiana Hospital Association 18 Educational Infusion Tom Seto, PharmD, Graduate Student, Department of Pharmacy Practice Kimberly Plake, PhD, Associate Professor, Department of Pharmacy Practice 20 Formula for Safety Erica Treadway, Third-Year Professional Student 22 Vital Signs John B. Hertig, PharmD, MS, Associate Director, Center for Medication Safety Advancement 24 CMSA Capsule Dissolving the numbers for 2012-13
our mission The Purdue University College of Pharmacy s Center for Medication Safety Advancement (CMSA) was established in March 2010 with the purpose of developing systems to reduce medication errors, prevent and manage adverse drug events, and promote safe medication use practices. CMSA is committed to serving the citizens of Indiana, the nation and the world through enhancing the discovery of safe medication use practices and delivering this knowledge to all who may benefit. Innovation and collaboration at the CMSA between faculty, staff and students link actionable discovery to entrepreneurial delivery, ultimately helping achieve a vision of making safe medication use common practice.
far-reaching remedies In spring 2007, I took a journey from the city of Eldoret, Kenya, via a remarkably poor road, to a clinic that annually provided care to several thousand patients, most of whom had AIDS. There in this clinic, which was not much larger than my Purdue office, the challenge was evident: How do you provide a medication distribution system that safely meets the needs of providers and patients in such a resource-constrained environment? Six years later, with more than 50 clinics established in Kenya, the challenge is more complex than ever. Addressing such needs requires pharmacists who are adept at formulating their own creative solutions by building on valuable lessons that others have previously learned. This is one reason I am so excited that the Center for Medication Safety Advancement has launched the International Medication Safety Fellowship and selected one of our Kenyan colleagues as the first fellowship participant. Since the center s inception, our vision has been that it would make a difference in the safe use of medications in a variety of health care settings. But, in all honesty, we did not envision that its impact would be as far-reaching so quickly. That the center s impact has stretched across state to national and now international borders is a great tribute to our dedicated staff that is vested in meeting pressing needs even globally to improve the safe use of medications. This annual report details for you how during the past year the center has established new training programs, developed new partnerships, extended its global reach and provided solutions to significant problems. Each step has been taken with the goal of making health care delivery safer and more effective for all patients. When I consider the growth and impact of our Center for Medication Safety Advancement, I immediately think of Lilly Endowment Inc., our generous partner. Lilly Endowment made the center a reality initially and is the backbone of continuing advancements. From the staff of CMSA and from the legions of patients touched by the center s work, we sincerely thank Lilly Endowment for our incredible partnership. Craig K. Svensson Dean of the College of Pharmacy and Professor of Medicinal Chemistry and Molecular Pharmacology 02 catalysts
salient solutions The Center for Medication Safety Advancement had a landmark 2012, and it was my sincere privilege to be part of it. Without question, our most significant success as it has been for many years was our staff. We continued our trajectory of growth and hired staff to address the increasing demand for our services. Some of our remarkable individuals and their contributions are highlighted throughout this report. For CMSA, the evolution of new scholarship and discovery of safe medication practices made this past year one to celebrate. We expanded our partnerships with Purdue University faculty, employed amazing graduate students who are inspired to help further our understanding of the medication use process, and continued to pursue meaningful innovation as a result of our discoveries. We remain true to our mission of taking proven research from the laboratory to the bedside, saving lives that would otherwise be lost to serious adverse events. All of our scholarship serves to fuel these life-saving innovations. And yet, our discovery and innovation would be fruitless without a firm commitment to engage regularly with professionals involved in patient care. The education and innovation that CMSA continues to provide so adeptly is helpful only if we are equally receptive to feedback regarding our efforts; so, we seek insight from across the country and from around the world. We are passionate about making safe medication use a common practice, and we hope we have managed to share that enthusiasm with you as you turn the following pages. Kyle E. Hultgren Director, Center for Medication Safety Advancement catalysts 05
dispensing teamwork A shared commitment to patient safety. A shared commitment to quality performance in the health care environment. A shared commitment to improved systems of care delivery. These pledges represent mutual goals of the partnership between the U.S. Department of Veterans Affairs (VA) and its academic partner, CMSA. Purdue s CMSA and the VA s department of Systems Redesign are in the third year of a collaborative effort to advance patient safety through systems improvement across the VA s spectrum of health care delivery settings and processes. In its initial stages, the partnership pinpointed and celebrated improvement of processes and implementation strategy training based on LEAN and Six Sigma methodologies for more than 900 VA employees. Then in 2012, additional initiatives were implemented for training more than 4,000 VA employees. CMSA and its consultantproviders are the face of Purdue University, a champion of patient safety as a critical platform of 21st century health care in America. In alignment with the National Quality Forum s overarching approach to improving patient care, the collaboration between CMSA and VA System Redesign is driving an exponential return on such quality and safety. catherine r. scott Education Program Manager, Center for Medication Safety Advancement 0 6 catalysts
culture of continuing education The innovative spirit, through partnerships with peers, is an important aspect of CMSA and the people who support its mission of furthering medication safety. The synergies between this mission and the goals of the College of Pharmacy s Office of Continuing Education (CE) are a perfect match for advancing the effort, and I have embraced that interdisciplinary teamwork since becoming the managing director of the Office of Continuing Education and Professional Development in the College of Pharmacy in June 2011. Naturally, medication safety was a major theme for our CE efforts throughout the past year. In partnership with CMSA, our flagship product, a medication safety webinar titled Medication Safety Essentials, became a huge success. It is a comprehensive introduction to medication safety concepts and tools that meet the standards of the medical, pharmacy and nursing accrediting bodies. This on-demand webinar series allows convenient access to recorded content about relevant medication safety topics; participants are actively involved in creating a culture of safety that focuses on systems redesign as well as outcomes for meeting patient needs. We cooperatively manage and accredit the Disclosure Training Program that was designed by Dr. Edward Dunn, who serves as the systems redesign director for the Lexington Veterans Affairs Medical Center and is on the faculty with the College of Public Health at the University of Kentucky. The program is structured to identify individual and institutional duties to disclose adverse events to patients and families defining the ethical, professional and legal basis for disclosure. The innovative, interactive activity incorporates risk management and patient safety to address immediate needs of the patient who suffers an adverse event, and to at the same time prevent similar harm to future patients. These are exciting times for us. In response to the circumstances behind the tragic meningitis outbreak in 2012, we have new focus on setting directives and establishing guidelines for compounding of prescription drugs. And in conjunction with CMSA, we are working with Purdue s Krannert School of Management to develop a certificate program geared to hospital setting representatives. Participants would build professional skills to further the cause of medication safety in the broader concern of patient safety. marlene o. heeg Managing Director, Office of Continuing Education and Professional Development, College of Pharmacy catalysts 09
cures for kenya In 2012 CMSA launched a novel international Medication Safety Fellowship as part of its commitment to deliver safe medication practices to the citizens of Indiana, the nation and the world. I was delighted to be the first fellowship recipient. How did it happen that the director of drug information and policy at the Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya, received such an honor? For a number of years, the College of Pharmacy at Purdue has partnered with Moi University and the hospital. The partnership has expanded knowledge on behalf of both parties, which set the stage for the creation of a fellowship. Receiving the fellowship has been an incredible experience for me, and it has promise of revolutionizing care for grateful patients in Kenya. I visited Purdue for four weeks. While working closely with CMSA faculty and staff, I learned new medication safety tools, honed important skills and gained experiences that can be implemented in my home country. I was principally focused on medication safety while at Purdue, but became familiar with operational, clinical and administrative pharmacy practice settings. I met with a variety of community, hospital and academic pharmacists for a detailed overview of how pharmacists practice in Indiana and began participating in focused CMSA projects that teach about necessary medication safety skills and tools. Coming from a resource-constrained setting in Kenya, pharmacy practice is very basic. We get information on pharmacy best practice from textbooks and online resources. Although I had seen some of the current pharmacy technology and processes via the Internet, getting this experience in person is totally different from reading or being taught in a class. It gave me a new perspective on the provision of health care. While at Purdue I began work on a major project to restructure the Tuberculosis Pharmacy in Eldoret, teaming with Dr. Jaclyn Jeffries, who was selected as the first Medication Safety Resident by CMSA in 2012. Dr. Jeffries later traveled to Eldoret to help implement the project. (See page 13.) Ultimately, the goal of the CMSA international fellowship program is to promote learning and sharing with a medication safety leader that will build a sustainable partnership and establish improved medication use systems far beyond Indiana. As it is doing in Kenya. celia chema Ngetich International Medication Safety Fellowship Recipient, Moi Teaching and Referral Hospital, Eldoret, Kenya catalysts 11
dose of discovery The Medication Safety Residency offered by CMSA was developed as a one-year, postgraduate training program that would enhance a pharmacist s knowledge, expertise and abilities in the expansive field of medication quality and safety. Specifically, my CMSA residency provided scholarship opportunities catered to my interests. I taught pharmacy students and other health care professionals throughout the state, nation and world, and also engaged with various organizations and initiatives where I was able to disseminate my new knowledge. I applied for and received grant funding for my longitudinal research project: What Is the Impact of Consumer Health Literacy for the Potential Unintentional Overdose of Acetaminophen: Patient s Perspectives? Participating in the CMSA-Kenya Medication Safety Fellowship Exchange Program was an incredible experience. Celia Chema Ngetich, a drug information pharmacist from Eldoret, Kenya, came to CMSA for a month in the fall and I traveled abroad in the winter. Together we were able to restructure the Tuberculosis (TB) Pharmacy in Eldoret with a goal of decreasing the number of patients lost to follow-up, and consequently limiting resistance to the limited TB medications available. It was rewarding, as well, to be part of the Indiana Hospital Association (IHA) and CMSA partnership. I did research to discover what high-risk medication classes lead to adverse drug events and subsequent readmissions, and those findings were shared in a webinar, self-assessment and full-day conference to more than 200 IHA members. The dynamic nature of the CSMA residency program, in combination with well-connected colleagues, transformed me from student to practitioner. Having improved my research, management and presentation skills through several enviable opportunities, I am better prepared for any challenge ahead. jaclyn A. jeffries Medication Safety Resident, Center for Medication Safety Advancement 1 2 catalysts
active ingredients CMSA offers semester-long internships to qualified Purdue College of Pharmacy students who are interested in obtaining experience in nontraditional pharmacy practice. We are three such PharmD students, whose experiential learning promises us a chance to be involved in professional research with Dr. Jaclyn Jeffries. Dr. Jeffries applied for a grant through the University of Tennessee Research Foundation at the beginning of her Medication Safety Residency year. The grant, initiated under the supervision of Dr. John Hertig, was accepted and funded by Cumberland Pharmaceuticals Inc., and a portion of the funding was allocated to hire us to help collect data for her longitudinal research project. The project title is: What Is the Impact of Consumer Health Literacy for the Potential Unintentional Overdose of Acetaminophen: Patient s Perspectives? The goal of the study is to identify patients health literacy regarding acetaminophencontaining products, find an effective method for educating/alerting patients to possible dangers associated with acetaminophen, and define who patients think is responsible for the safe consumption of acetaminophen-containing products. Our experience with CMSA is helping us hone our skills in time management, teamwork, research and communications as we assist Dr. Jeffries with the application for Institutional Review Board approval, employ the research methodology once it s designed and interview patients to collect data. jessica smith Second-Year Professional Student, College of Pharmacy Elizabeth Gill Second-Year Professional Student, College of Pharmacy Rebecca Schoen Third-Year Professional Student, College of Pharmacy catalysts 15
side-by-side effects In March 2010 the Indiana Hospital Association (IHA) and its Indiana Patient Safety Center put forward a bold aim: To make Indiana the safest place to receive care in the country, if not the world. Through its network of 11 regional patient safety coalitions, IHA supports the collaborative effort of hospitals and health care providers in-state and across the United States to improve care quality and patient safety. Purdue s CMSA is an instrumental partner in IHA s Coalition for Care. IHA is linked to a national hospital initiative that relies on education and technical assistance among hospitals in order to prevent patient harm and hospital readmissions. As part of a contract with IHA, the Purdue center provides information about adverse medication events and their impact on patient readmissions. CMSA also developed Medication Safety Essentials, an online, on-demand course that is helping to standardize interprofessional medication safety competencies in Indiana. I believe that perhaps the most meaningful way in which CMSA is contributing to the long-standing sustainability of Indiana s efforts to improve medication safety is through the Medication Safety Alliance. As this unique model develops, health care providers from all disciplines will benefit tremendously from enhanced efforts to prevent medication-related harm and also build networks for sharing evidence-based practices. IHA is fortunate to have such dedicated partners at the CMSA. Our shared passion for developing safe and reliable systems of care to prevent harm to patients will serve Indiana for years to come. betsy lee Director, Indiana Patient Safety Center, Indiana Hospital Association catalysts 17
educational infusion As a graduate student in the Department of Pharmacy Practice, I have had the opportunity to work with Dr. Kimberly Plake, an associate professor in the department, whose research is focused on learning and assessment. We have a partnership with CMSA to pursue research on medication safety and patient safety. The long-term goal of our research is to develop interventions that reduce medical errors in institutional health care settings, thereby improving patient health outcomes by preventing adverse events. Simulation serves as a valuable tool in creating authentic experiences for individuals to practice their skills in a safe virtual environment in a real-time setting. Virtual environments also can include components of team interactions, stressors and confounding variables that are representative of the fluid work environment in a health care setting. At the completion of our study, we expect that we will have constructed a measurement tool to evaluate efforts for reducing medical errors. We also expect to have developed a real-time, interactive simulation module that mimics processes in an institutional setting in order to educate health care providers about how individual and/or team actions may/can prevent medical errors from occurring. This study, therefore, can have a positive impact on patient care through the reduction of medical errors and improvement in patient outcomes. Tom W. Seto Graduate Student, Department of Pharmacy Practice kimberly S. Plake Associate Professor, Department of Pharmacy Practice 1 8 catalysts
formula for safety Safe medication use has been a growing passion of mine since taking the medication safety elective course at Purdue during the 2012 spring semester. The course included interactive simulations and open discussions to demonstrate ways in which health care systems can fail patients. One simulation I especially enjoyed was of a patient s journey through the health care system from checking in at a doctor s office to picking up a prescription at a pharmacy. I came away with a better understanding of the experience for both patient and health care professional, which included each person s frustrations and where errors might occur. Thanks to that rewarding experience, I was motivated to become involved; a CMSA internship was the perfect opportunity. I worked with Dr. John Hertig to create simulations that give students in the class a hands-on simulated opportunity such as dispensing prescriptions in a community setting and administering medication in a hospital. It s important to keep in mind that if we can understand what a certain role entails, we can recognize potential pitfalls at that step of the process. In addition, by putting ourselves in someone else s shoes, we realize that efforts to improve the health care system should not only include how we as pharmacists complete a task but also how we work together as a health care team. erica Treadway Third-Year Professional Student, College of Pharmacy catalysts 21
vital signs It is my sincere hope that after reading this annual report you have new appreciation for the growth and expanded impact we achieved at CMSA in 2012. We elaborated on our training programs, including the Medication Safety Residency and International Medication Safety Fellowship. There was exciting news about expanded partnerships with the Indiana Hospital Association and our own faculty and staff at Purdue University. Were you fascinated by the didactic teaching and undergraduate research projects that are part of our avid commitment to students? All are successes we continue to celebrate. Although proud of our successes, we continue to innovate in the name of patients, ensuring that the solutions we develop and teach are tackling the health care challenges of today and making medication use safer for the patients of tomorrow. Given this expansion, passion and unyielding desire to deliver, several new CMSA projects and initiatives are already well under way and likely topics for next year s annual report. A few examples of up-and-coming work will give you insight into our future. We continue to embrace our commitment to education and training, demonstrated by our launch of a Medication Safety Fellowship program in cooperation with Eli Lilly and Company and the Food and Drug Administration that is set to begin July 1. Our partnership with the Indiana Hospital Association continues to grow as our newly formed Indiana Medication Safety Alliance, highlighted in this year s report, launches its first major initiative focused on statewide reporting of adverse drug events. Our work with Purdue faculty is expanding and producing innovative, transferable research that will enhance the training and impact of medication safety teaching through simulation. In summary, the outstanding projects and partnerships highlighted in this annual report, combined with the limitless future of CMSA, have us all looking toward a bright horizon. CMSA has a discovery-with-delivery mission that has never been stronger as we continue to produce results that translate into safer medication practices for the citizens of Indiana and across the world. john b. hertig Associate Director, Center for Medication Safety Advancement catalysts 23
24 catalysts eight International medication safety initiatives 172,458 miles traveled cmsa capsule dissolving the numbers for 2012-13 thirty state and national presentations 1,511Hours training purdue students 77 performance improvement certifications one mission making safe medication use common practice 45 indiana medication safety alliance members 980ce medication safety hours completed 84h ealth systems working with CMSA 4,025 health care professionals trained catalysts 25
for a consultation We encourage you to explore our CMSA website and bookmark it as a gateway to some of the most up-to-date medication safety information available. The site explains CMSA, details many current projects, and links you to new presentations and publications as they become available. Stay closely tuned to our medication safety blog, a great source of hot topic information. www.pharmacy.purdue.edu/cmsa CMSA gratefully acknowledges the generous support of the lilly endowment
Center for Medication Safety Advancement 6640 Intech Blvd., Suite 120 Indianapolis, IN 46278-2012 317-275-6088 www.pharmacy.purdue.edu/cmsa College of Pharmacy 575 Stadium Mall Drive West Lafayette, IN 47907 765-494-1361 www.pharmacy.purdue.edu EA/EOU Produced by Purdue Marketing and Media PHA.13.3283