Clinical alert reporting:

Electronic solutions to the

rescue!

Samantha Hilmi, Claire Tobin, Ralph

Baker

Royal Perth Hospital (RPH)

WAMSG Symposium – September 2016

Background

Function within PAS

Records critical medical information

Advises clinicians on potentially life-

threatening situations

anaesthetic

medical

drug related

The RPH Experience

Management of clinical alerts not optimal

poor reporting rates

reported alerts not reviewed

no mechanism for feedback

inferior paper-based method

Impetus for change

WA Clinical Alert (Med Alert) Policy – February

2014

RPH Objective

Implement and promote an efficient and

safe system of reporting and managing

clinical alerts in accordance with Policy

Method

Multidisciplinary Clinical Alerts Committee

(CAC)

develop improved system of reporting

policy and procedures on managing clinical

alerts

implement changes

educate staff and promote reporting

Meet monthly to review reports

Data Collection

Staff survey (June 2015)

27 medical and nursing respondents

52% aware of clinical alert information in

iSOFT Clinical Manager

15% aware of Clinical Alert Policy

4% aware of reporting form

Form readily available on 43% of wards

Electronic Form

Development of electronic form

consultation with information technology

and medical illustrations

repeated testing

application allowed for electronic reporting

submission to a nominated email account

patient confidentiality maintained

Coders enter alerts on PAS

CAC review reports monthly

Electronic Form

Staff Awareness

Hospital-wide education and promotion

PR consulted

departmental orientation and education

sessions

induction

slide show presentation with key messages

Medication Safety Newsletter article

staff forum

Outcomes

Effective committee established

reports standardised and reviewed for

appropriateness

Efficient means of reporting implemented

readily accessible electronic form

alerts promptly available on PAS

Improved awareness on reporting

ongoing promotion and education

Outcomes – Supporting Data

Alerts promptly on PAS/iSOFT

days or weeks reduced to max 2 hours

Audit of serious drug reaction alerts

January-June 2015 vs 2016

Outcomes – Supporting Data

5/5

1/14

0 20 40 60 80 100 120

Jan-Jun 2016

Jan-Jun 2015

Serious drug reactions - rate of reporting

Reporting rate (%)

Conclusions

Achieved our objectives of promoting and

implementing an efficient and safe system

of reporting

Improved patient safety

Relevance to Other Sites

The WA Clinical Alert Business User Group

aware of the RPH processes

Potential implementation at other WA

Health organisations

Acknowledgments

RPH Clinical Alerts Committee members

Ms Ann Berwick, Medicines Information

Pharmacist

Clinical alert reporting:

Electronic solutions to the

rescue!

Samantha Hilmi, Claire Tobin, Ralph

Baker

Royal Perth Hospital (RPH)

WAMSG Symposium – September 2016