Eliminating Potassium Administration-Related Patient Safety Events with Epic

Potassium is critical to nerve and muscle cell function, but hyperkalemia, or potassium levels that are too high, can cause heart problems. By making sure clinicians had the right information at the right time as they’re ordering medications for patients, Rochester Regional Health reduced the number of potassium administration-related patient safety events for patients at high risk of hyperkalemia to zero and reduced these events for patients at lower risk of hyperkalemia by 80%. RRH is just one organization using Epic to improve safety – last year, doctors used Epic to prevent an estimated 3.4 million potentially harmful prescription drug interactions.

RRH’s health informatics team worked closely with clinicians to design advisories in Epic that show patients’ most recent potassium levels when clinicians administer medications. Epic notifies clinicians when a patient has high potassium so providers can adjust the medication and prevent hyperkalemia.

“This case is an exemplar of how Epic can drive widespread improvement in a learning health system,” said Dr. Balazs Zsenits, CMIO for RRH. “Beyond creating a highly effective decision support tool to keep patients safe and clinicians happy, we also created reports, practices, and culture to improve our safety projects. This ensures our improvements are truly significant and our results are sustainable and scalable.”

Epic community members can view RRH’s UGM presentation slides and audio on the UserWeb.