Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

3056 — Results of Aggregate Root Cause Analysis of Adverse Drug Events in the VA System

Mills PD (NCPS Field Office) , Neily J (NCPS Field Office), Kinney L (NCPS Field Office), Bagian J (National Center for Patient Safety), Weeks WB (NCPS Field Office)

To analyze all serious reported adverse drug events (ADE) occurring in VA over a one-year period and report common root causes, effective actions implemented to address root causes, and organizational factors associated with improvements.

Every medication-related root cause analysis submitted to the Veterans Affairs National Center for Patient Safety in FY04 (143 reports), and one medication related aggregated RCA from each facility (111 reports covering 4834 ADEs) were reviewed and coded. Facilities were interviewed about their reports.

Root causes of adverse drug events included: problems with policies or procedures (19.5%), communication problems (18.4%), equipment problems (12.9%), medication dispensing (12.1%), problems with training (9.1%), and staffing (6.5%). The largest class of medication involved was narcotics (21.0%), followed by anticoagulants (14.7%), chemotherapy (11.2%), diabetes medications (9.1%), and cardiovascular medications (7.7%). The most common type of ADE was wrong dose of medication (31.5%), wrong medication (13.3%), failure to give medication (11.9%), giving the medication to the wrong patient (10.5%), and insufficient monitoring of a patient while on medication (6.3%). Every RCA report includes an action plan designed to address the root causes. Actions involving improvements in equipment or computers (N=46) or clinical care (N=127) were associated with improved outcomes (Rho=.100, p=.018, and Rho=.101, p=.017). Changing the process of medication order-entry through the use of alerts or forcing functions was positively correlated with improved outcomes (Rho=.097, p=.022). Higher implementation rates of actions were correlated with senior leadership support (Rho=.310, p=.001), middle management support (Rho=.236, p=.011), and getting feedback before implementing (Rho=.239,p=.010). Facilities that reported improved outcomes were more likely to have a system for tracking improvements (Rho=.229, p=.013), senior leadership support (Rho=.250, p=.006), front-line staff support (Rho=.206, p=.027), and to have obtained front-line feedback before implementing changes (Rho=.198, p=.033).

Changes at the bedside and improvement in equipment/computers were associated with reduced ADEs within the VA; well organized tracking and support from leadership and staff were characteristics of facilities that were successful at improving outcomes.

Ongoing analysis of root-cause datasets may help VA facilities determine which interventions are most likely to be associated with improved outcomes. A menu of effective actions for specific ADEs is available.