Improving Medication Safety for Patients with Adrenal Insufficiency Using Electronic Health Record Optimization

Life-threatening adrenal crisis is preventable with timely administration of a stress dose of hydrocortisone, but recognition is often delayed. Sentinel patient safety events in 2020 highlighted the need to standardize adrenal insufficiency management. The primary aim of our quality improvement project was to reduce adrenal insufficiency medication errors in the emergency department (ED) by 10% from the baseline in 2 years.

We included patients younger than 21 years with adrenal insufficiency and a prescription for parenteral hydrocortisone sodium succinate or oral hydrocortisone (prescribed by endocrinology) seen at our hospital between January 1, 2019, and September 30, 2023. Electronic health record (EHR) optimization changes included usage of a best practice advisory to improve visibility of adrenal insufficiency diagnosis and standardization of orders, steroid action plans, and education documentation. ED medication errors were defined as ED encounters with an emergency service index score of 1 or 2 with suboptimal stress dose (<50 mg/m² of hydrocortisone sodium succinate) administration. The secondary outcome measure was safety reports related to medication errors in the ED or ambulatory setting. We analyzed outcome measures using statistical process control and tracked usage rates of EHR changes.

We included 776 patients and 920 ED encounters. ED medication errors reduced from a baseline of 21% to 13.9% by study end. The interval between safety reports increased from an average of 74.4 to 775 days. Process measure use was 60% or greater for the problem list, best practice advisory, and steroid action plan, and 34% for education documentation.

We successfully leveraged EHR optimization to standardize adrenal insufficiency management, increase visibility of critical information, and significantly reduce medication errors.