Formative Evaluation of VA Adverse Drug Event Reporting System for Next Steps to Improve Patient Safety

ANJU SAHAY, PhD
Dept. of Veterans Affairs

The Department of Veteran Affairs (VA) has developed the VA Adverse Drug Event Reporting System (VA ADERS) an integrated web‐based application available in all VA facilities. The VA ADERS provides a standardized method for VAs to report and review adverse drug events. The VA Medication Safety (MedSafe) QUERI Program, in collaboration with the VA Office of Pharmacy Benefits Management Services (PBM) is interested in understanding how pharmacists at VA sites use VA ADERS with a focus on adverse drug events related to intended or unintended use of medications.

Pharmacists at all the VA sites.

In November 2021, the MedSafe QUERI Program and PBM jointly conducted a web-based survey. VISN (Regional) Pharmacy Executives at 18 VISNs were emailed a survey weblink to forward to the Chiefs of Pharmacy at all the sites within their own VISN who, in turn, identified a site pharmacist having experience with VA ADERS to complete the survey. The goal was to understand how VA sites are currently using VA ADERS to report adverse drug events. Survey response rate was 67.1% (N=98).

The majority of respondents (pharmacists) reported their primary role as Pharmacy Manager (32.0%), Patient/Medication Safety Pharmacist (20.6%), Clinical Pharmacy Specialist (17.5%), Pharmacoeconomist (7.2%), Chief Of Pharmacy (6.1%), Clinical Specialty Pharmacist (5.2%) and Staff Pharmacist (3.1%). The remaining pharmacists (8.2%) identified themselves singularly (1.0%) in each of the remaining 8 primary roles. Regarding regular use of VA ADERS by pharmacists at their own site, most pharmacists reported that VA ADERS is used regularly (85.6%) while the remaining reported irregular use (14.4%). Regarding the timeliness of reporting and review of adverse drug events (ADEs) in VA ADERS, the three most common ways listed were: 1. Reported as soon as possible (25.2%); 2. Collected and reported by assigned staff once a month (24.4%); and 3. Reporting was a combination based on staff reporting and draft created from the Allergy/Adverse Reaction Tracking System (ARTS) reports (20.0%). Most commonly employed strategies for reporting ADEs in VA ADERS at each site were: : one person coordinating report entry, but multiple staff enter reports (30.3%);and one person primarily responsible for entering reports (20.0%) and residents do the reporting (27.7%). Pharmacists reported sharing local safety issues identified in VA ADERS with others within their own site (50.0%), within Pharmacy Service at their own site (34.7%), within their own VISN (13.1%), and outside their own VISN (2.3%).

VA ADERS is perceived by pharmacists as a valuable system for their sites to report adverse drug events and to share local safety issues for patient safety.