Background. Most safety issues in primary care arise from adverse drug events. Team Resource Management intervention was developed to identify systemic safety issues to design and implement interventions to address prioritized issues. Objectives. Evaluate impact of intervention on rates of events and preventable events in a vulnerable population. Design. Cluster randomized trial. 12 practices randomly assigned to either: (1) Intervention; (2) Intervention with Practice Enhancement Assistants; (3) No intervention. The intervention took 12 months. Main Outcome Measure. Rate and severity of events and preventable events measured using a Trigger Tool chart review method for the 12-month periods before and after the start of the intervention. Results. In the ‘‘intervention with Assistants’’ group there was a statistically significant decrease in the overall rate of events and in the rate of moderate/severe events. Analysis of Variance with study arm and time as the factors and moderate/severe events as the outcome showed a significant interaction between arm and time supporting the notion that the ‘‘Intervention with Assistants’’ practices had a greater reduction in moderate/severe preventable events. Conclusions. The intervention had a significant effect on medication safety as estimated using a trigger tool. Further exploration of role of Assistants and trigger tool is warranted. 1. Introduction Medication use is recognized to be a high-risk activity across all settings. A recent Institute of Medicine (IOM) report on this subject acknowledges that the rates and impact of medication errors are huge but are poorly understood [1]. The President of the Institute of Safe Medication Practices (ISMP), Michael Cohen [2], in his testimony to a committee of the US Congress estimated that the dollar cost of adverse drug events was about $200 billion across all settings. In ambulatory settings, medication errors and adverse drug events (ADEs) are one of the most important safety issues. A study based on the National Ambulatory Medical Care Survey (NAMCS) found that office-based physicians prescribed at least 1 inappropriate medication to nearly 8% of the elderly who received prescriptions [3]. Another study of ambulatory elderly patients with polymorbidity and associated polypharmacy documented that 35% reported experiencing at least one ADE within the previous year [4]. Gurwitz and colleagues have estimated (by extrapolation) that Medicare enrollees alone suffer approximately 500,000 preventable ADEs per year [5]. A 2003 report of a multidisciplinary group (composed
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