The easiest ADR (adverse drug reaction) to avoid is the second one, not the first one.
CLOSE TO A DECADE AGO Vancouver resident Johanna Trimble took a seaplane trip to Victoria for an important mission and she brought one important thing. A story. And that story has made all the difference.
She travelled that day with two Vancouver emergency room physicians, who invited her along to a meeting with officials at the BC Ministry of Health. The trio’s goal was to try to convince officials at the Pharmaceutical Services Division that BC had a very big, but very solvable problem on its hands. It concerned adverse drug events (ADEs), drug reactions that can be serious enough to cause hospitalizations, serious illness and sometimes death.
Johanna was unwittingly thrust into the position of witnessing the care of both her elderly mother-in-law, and her stepmother who were prescribed drugs and hospitalized due to adverse drug reactions. Equipped with both the wisdom to question a drug and the determination to question the doctors, in both cases she managed to get the culprit pills stopped. You’d think that would be the end of the story, but in both cases, the offending drug was represcribed by a different doctor, in a different clinic, and wham, back to the emergency room for a repeat episode.
A doctor from a different mold
Emergency room physician Dr Corinne Hohl has seen her share of people showing up in the emergency department suffering the effects of prescribed drugs. Adverse drug events are a leading cause of emergency department visits and unplanned hospital admissions. Shockingly, of those in the emergency department because of an adverse drug event, 29 percent are there because they are having a repeat adverse reaction to the same drug (or drug class) that had brought them to the ED previously.
Dr Hohl accompanied Johanna on that trip to Victoria, and she speaks with the kind of verve and enthusiasm of someone who’s out to change the world. She recounted an incident that made its mark on her. An elderly woman was admitted to her emergency room in Vancouver General with subdural hematoma—a fairly serious head injury—related to a fall. The patient was taking fairly high doses of fentanyl patches, which were likely the cause of the fall. After being hospitalized for weeks, the patient was slowly switched off the fentanyl to a safer drug. Not long after, the same woman appeared in her emergency room after another fall, this time with multiple rib fractures.
“And guess what?” she told me. “She was on the fentanyl again. Basically back on the drug that had previously been related to her fall.”
Dr Hohl had been working on how to get a handle on this problem for several years before that meeting with the Ministry. “They thought we were going to show up on the phone but we showed up in their offices in person and their jaws were on the floor.” Her request was concise: she wanted a very simple change to PharmaNet, BC’s comprehensive province-wide drug data system that tracks every prescribed drug in the province. Why not modify it so that it would allow physicians and pharmacists working in hospitals to enter any drug-related ADEs on the patients’ chart? She reasoned that if that information, like an allergy, for example, was a routine part of a patients’ medical record, then the problem of repeat ADEs could be eliminated overnight.
“We did all kinds of modelling, to show them how expensive and serious the issue of repeat adverse drug events was. In my presentation I compared it to the opioid epidemic and I showed them how many people died from this problem that is being completely ignored,” she said. Not to be outdone by the enormity of the problem, she also made a promise: “I told them I was going to design a solution for them that was unique across the world.”
It helped immensely that Johanna was there—just a regular BC citizen who has seen this problem firsthand, twice. Her story probably helped convince the Ministry of Health officials that change needed to happen. After all, how many BC seniors are on the receiving end of an avoidable prescription mistake that could be fatal?
The meeting was probably the inflection point that is now slowly reducing the problem of repeat ADEs in BC. But as Dr Corinne Hohl found out, big system or cultural changes in medicine don’t happen overnight.
Research money and pizza
From the time that Dr Hohl recognized the problem of repeat ADEs, until some (not all) hospitals began acting on the information from BC PharmaNet, eight years had passed.
The delays were understandable but frustrating. Once she got over the bureaucratic hurdles that stymie all but the most determined, Dr Hohl saw that making software changes to a large and impossibly complex computer data system was no walk in the park. And then there’s what is known as the “human factor”—the culture of medicine would need clinicians, nurses, doctors and pharmacists to recognize, record and later seek out any ADEs that are in a patient’s chart.
What fuelled her work to make headway on an impossibly complicated task came down to research money and pizza.
Many times smart clinicians working in our medical system will see a problem that needs a solution, yet they hit the brick wall of their colleagues or administrators asking “where’s the evidence?” Inertia is easier, and if you don’t have a study to back up what you’re proposing, you better go get one.
Dr Hohl went to the research world, getting grants from various sources including the Canadian Institutes of Health Research (CIHR), which helped pay for a gold-standard study, a randomized controlled trial (RCT), and allowed her to tap into the expertise of people on the front lines.
A system like this needed a user-friendly interface for physicians and pharmacists, so that meant a kind of “action-research” approach. She worked tirelessly with Ellen Balka, a communications specialist and qualitative researcher at SFU, who helped her dig deep into the principles of behaviour change. This also meant constantly going back to those in clinical practice.
“We really needed to bring in that expertise to figure out how clinicians think, work out the details of proper drop-down menus, data standards, and so on,” said Hohl. “We kept buying pizza for the pharmacists. They told us, change this, make this like this, and so on. All those sorts of design features were exceedingly important.”
The software application Hohl and her team created is called ActionADE, designed to enable front line clinicians to document adverse drug events by communicating to a central medication dispensing database.
Dr Hohl’s system is not province-wide yet, but it has been implemented in nine acute care hospitals already. It still needs ongoing investment to upgrade software and pay for staff, mostly pharmacists, to enter the data into patient records.
At the end of the day she has shifted the culture, reminding her colleagues of the enormity of potential adverse drug events, and the need to make sure peoples’ medications are as safe as they can be. All this is part of the growing patient safety movement, where adverse drug events are better known, and many people are becoming aware that tracking and recording them can be lifesaving.
Johanna Trimble doesn’t mind being “the voice of the patient” when it comes to speaking truth to power. And she’s darned good at it, becoming one of our province’s most vocal patient safety advocates. About ActionADE she says, “in the absence of such a system, it all comes down to the family. The family has to remember the drug information and these side effects, because nobody else is. The family is the continuity. If the family doesn’t know they have to do that, then somebody might die.”
Luckily now in BC, the family is going to get some help in this area.
Alan Cassels is a researcher and writer about pharmaceutical policy issues. He lives in Victoria. A webinar discussing Dr Hohl’s research is posted at the website of the Therapeutics Initiative.