QI Initiative Focuses on Improving Medication Safety

Adverse drug events (ADEs) nearly always present an opportunity for improvement. Unfortunately, adverse events from nephrotoxic medication administration are common, and frequently preventable, among children with kidney disease. Children with kidney disease are often medically complex which heightens their risk for polypharmacy and drug-drug interactions. Most medications are safe for kidney patients if given at the proper dose or time interval, but this requires careful attention to a patient’s level of kidney function to ensure that the right dose gets to the right patient at the right time.

To address this issue at Children’s Mercy, Darcy Weidemann, MD, Pediatric Nephrologist and Medical Director, Quality and Safety in Nephrology, and a multidisciplinary workgroup, recently led a quality improvement initiative to: 

• Heighten clinician awareness of patient eGFR;
• Improve contrast safety to contemporary evidence-based standards of care;
• Refine medication ordering and pharmacy verification of medications. 

“Our patients are seen in all kinds of care settings,” said Dr. Weidemann. “We need to make sure we can deliver safe care and that staff have the right information easily  accessible to know they are doing the right thing for our patients wherever they are seen.”

In 2022, Children’s Mercy became one of the first pediatric institutions in the country to integrate a newer and more precise eGFR calculator into the electronic medical record to enable improved screening of kidney function, earlier diagnosis of impairment, more accurate medication dosing, and enhanced patient education. The calculator was developed through the NIH-funded Chronic Kidney Disease in Children (CKID) study, co-led by Children’s Mercy.

Building on that integration, the QI workgroup held a workshop at which detailed process maps were developed for both inpatient and outpatient medication prescribing practices within Children’s Mercy. This workshop led to the creation of three separate workgroups.

One workgroup focused on improving clinician recognition of eGFR. This group integrated the CKiD U25 (under 25) eGFR estimating equation into the patient’s laboratory profile within the EMR, creating a provider-facing eGFR.

A second workgroup incorporated evidence-based guidelines into the EMR for appropriate use of radiology contrast agents which can potentially be nephrotoxic. An internal Care Process Model was developed which includes algorithms for standardized hydration protocols to reduce the risk of contrast-associated nephropathy.

The third workgroup created and integrated into the EMR a standardized list of medications at high risk for ADEs related to impaired eGFR into the electronic pharmacy verification system. Additionally, this team incorporated the same medication list into a prescriber alert which notifies prescribers when they are ordering a nephrotoxic medication on a patient who has laboratory evidence of impaired kidney function.

“We are still early in the process. This requires a lot of infrastructure change, so we’re being very thoughtful and methodical with implementation,” says Dr. Weidemann.  “As we implement new processes, we're collecting data on how often these interventions lead to meaningful change while minimizing alarm fatigue. Our goal is to reduce ADEs by at least 20% by July 2024.”