In most health systems—even those with well-established electronic medical records—reporting adverse events is a spotty and not always standardized process.
New software called KBCore may change that. In November, the program’s developer, CRG Medical, won the Reporting Patient Safety Events Challenge issued by the Office of the National Coordinator for Health Information Technology (ONC), in part due to the software’s flexibility: It enables users to generate error reports from any mobile device or within the EMR simply by scanning a patient’s bar code. The program also is garnering positive reviews for the depth of relevant data that users can rapidly access.
“Most reporting systems I’m familiar with don’t take advantage of the existing electronic data [they contain],” said Matt Grissinger, RPh, the director of error reporting programs at the Institute for Safe Medication Practices. “We already have the patient’s name, room number, the medications they’re on, their dosages and so on—yet [unlike KBCore], many systems make you re-enter [that information].”
Although several other programs allow pharmacists to document their phone calls and let users pull patient data right into the program, “they’re not adverse event reporting programs like this one is,” Mr. Grissinger said.
Jerry Fahrni, PharmD, a product manager at Talyst who frequently blogs on new pharmacy technologies and tweeted the news about KBCore, also sees the potential of the new software. “It’s a big deal to have all that information at your fingertips,” he said. “Every drug’s NDC [National Drug Code] number potentially can be found in the bar code, and by scanning it, this system can accurately populate the [fields for the] strength of the drug, the manufacturer and all the other data.” The program also allows for the input of additional information once the initial report has been submitted.
KBCore was one of 13 submissions to the ONC Challenge, which evaluated reporting systems based on five factors: effectiveness; usability and design; innovation and creativity; integration with electronic medical records (EMRs) and secure transmission capabilities; and ability to leverage the nationwide health information network, an initiative for the exchange of health care information being developed under the auspices of ONC.
“The platform itself was easy to use and clear to understand; we saw submissions in this and other challenges that involve reporting, and input can be quite messy,” Adam Wong, a management and program analyst at the ONC, told InformationWeek Healthcare. “If the solution isn’t much easier to use than what already exists, it’s not moving things forward.”
No Gold Standard Yet
Dr. Fahrni agreed that current adverse drug event reporting systems are in need of improvement. Indeed, at present, “there’s no nationally recognized gold standard system for adverse event reporting; there’s no software that really stands out,” he said. “In most hospitals today, people will do it manually. There’s no great way to collect that data and get it to a centralized spot.”
Vicki Tamis, PharmD, BCPS, a clinical quality informaticist at PeaceHealth Southwest Medical Center, in Vancouver, Wash., also sees flaws in how most hospitals manage the tracking and reporting of adverse drug events. “We find that people who submit reports into the electronic system don’t always get all the accurate information entered,” Dr. Tamis said. “Depending on the reporting program, sometimes the dosage information or route of administration isn’t correct.” Thus, the medication error report “is usually just a starting point. Almost every time you have to review a patient’s record for an adverse event or medication safety problem, it can take a lot of detective work to pull the full story together.”
As for the KBCore software, Dr. Tamis said it looked promising. But she noted that it could be improved by adding an automated system response when specific drugs or doses of certain drugs are given. “It would be nice if somebody could design a product that would automatically, if a certain dose of X medication is given, pull in [elements] of analysis you would need,” she said.
While praising the KBCore application, Mr. Grissinger cautioned that any adverse event reporting program is only as good as the reporting culture at each hospital. “You could buy the Cadillac of reporting programs, but if your environment is punitive, it still won’t happen.”
The other complaint ISMP hears frequently, he noted, “is that institutions have a big rollout of a reporting system and then people hear nothing and see no action being taken when they do report events. A program like this can make the process easier, but at the end of the day you have to change the culture.”