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The information contained in these resources does not necessarily reflect the views of the Partnership for Patients, the Centers for Medicare and Medicaid Services, The United States Department of Health and Human Services, nor the United States government.

Adverse Drug Events (ADE)
Title Description
“How-to Guide: Prevent Adverse Drug Events (Medication Reconciliation)” (Institute for Healthcare Improvement [IHI]) This how-to guide describes key evidence-based care components to prevent adverse drug events (ADEs) by implementing medication reconciliation at all transitions in care (at admission, transfer, and discharge), describes how to implement these interventions, and recommends measures to gauge improvement.
“How-to Guide: Prevent Adverse Drug Events (Medication Reconciliation) — Pediatric Supplement” (IHI) This how-to guide specifically tailored for pediatrics describes key evidence-based care components to prevent adverse drug events (ADEs) by implementing medication reconciliation at all transitions in care (at admission, transfer, and discharge), describes how to implement these interventions, and recommends measures to gauge improvement.
“Preventing Adverse Drug Events (Medication Reconciliation): Patient and Family Fact Sheet” (IHI) This resource for patients and families provides an overview of how to prevent adverse drug events by reconciling medications at all transitions in care (at admission, transfer, and discharge). Available in English and Spanish.
“Reducing Medication Errors” (Massachusetts Coalition for the Prevention of Medical Errors) A Web site listing initiatives to reduce medication errors in anticoagulation medicine, ambulatory settings, acute care facilities, long-term care facilities, and consumer safety.
“MATCH Medication Reconciliation Toolkit” (IHI) The medication reconciliation initiative at Northwestern Memorial Hospital, called MATCH, included development of a toolkit to help hospital and outpatient practice staff.
“Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs” (U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality [AHRQ]) Many ADE injuries and resulting hospital costs can be reduced if hospitals make changes to their systems for preventing and detecting ADEs. Some approaches found to be successful are summarized in this Web site.
“Preventable Adverse Drug Reactions: A Focus on Drug Interactions” (U.S. Department of Health & Human Services, U.S. Food and Drug Administration [FDA]) This learning module was developed based on a needs survey sent to all third-year medicine clerkship directors and all medicine residency program directors in the United States.
“Safe Use Initiative: Collaborating to Reduce Preventable Harm from Medications” (FDA) The mission of the Safe Use Initiative is to create and facilitate public and private collaborations within the healthcare community. The goal of the Safe Use Initiative is to reduce preventable harm by identifying specific, preventable medication risks and developing, implementing and evaluating cross-sector interventions with partners who are committed to safe medication use.
“ISMP” (Institute for Safe Medication Practices) A comprehensive Web site with medication safety tools, reports, resources, products, alerts, and videos.
“NCC MERP” (The National Coordinating Council for Medication Error Reporting and Prevention) Founded by the United States Pharmacopeia, the mission of NCC MERP is to maximize the safe use of medications and to increase awareness of medication errors through open communication, increased reporting, and promotion of medication error prevention strategies.
“Adverse Drug Reaction Surveillance: Practical Methods for Developing a Successful Monitoring Program” (Medscape from WebMD) Article. Barriers to improved reporting of adverse drug events (ADEs) are evaluated and mechanisms to overcome these barriers are presented. The impact of ADR surveillance on the evaluation and modification of the medication-use system at Northeast Health to improve patient quality of care is described.
“Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention” (Journal of the American Medical Association) Article. Assessment of the incidence and preventability of adverse drug events (ADEs) and potential ADEs, with analysis of preventable events to develop prevention strategies.
“MedWatch: The FDA Safety Information and Adverse Event Reporting Program” (FDA) FDA gateway for clinically important safety information and for reporting serious problems with human medical products.
“Adverse Event Reporting System (AERS)” (FDA) The Adverse Event Reporting System (AERS) is a computerized information database designed to support the FDA’s post-marketing safety surveillance program for all approved drug and therapeutic biologic products. The FDA uses AERS to monitor for new adverse events and medication errors that might occur with these marketed products.
“Preventing Medication Errors: Quality Chasm Series” (Institute of Medicine of the National Academies) The Institute of Medicine Report, Preventing Medication Errors, puts forward a national agenda for reducing medication errors based on estimates of the incidence and cost of such errors and evidence on the efficacy of various prevention strategies.
“Trigger Tool for Measuring Adverse Drug Events” (IHI) This tool includes a list of known ADE triggers and instructions for measuring the number and degree of harmful medication events. The tool provides instructions and forms for collecting the data you need to measure ADEs per 1,000 Doses and Percent of Admissions with an ADE.
Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency Departments, 2008 (AHRQ, Healthcare Cost and Utilization Project) This AHRQ Statistical Brief presents data from the Healthcare Cost and Utilization Project (HCUP) on medication - or drug-related adverse outcomes that were seen in hospitals in 2008. In addition, data is also presented on treat-and-release emergency department visits.
Hospital Incident Reporting Systems Do Not Capture Most Patient Harm (U.S. Department of Health & Human Services, Office of Inspector General) A summary of the January 2012 Office of the Inspector General (OIG) report on the state of hospital incident reporting. The conclusion (concurred with by AHRQ and CMS) is that strengthening hospital reporting systems and practices is essential.
“WHO Programme for International Drug Monitoring” (World Health Organization) The aims of the WHO Pharmacovigilence Programme are to enhance patient care and patient safety in relation to the use of medicines, and to support public health programs by providing reliable, balanced information for the effective assessment of the risk-benefit profile of medicines.
“Safe Medication: Your Trusted Source of Drug Information” (American Society of Health-System Pharmacists [ASHP]) A database and resource gateway to help patients use medicines safely and effectively.
“Videos and Podcasts — Speak Up: Take Medication Safely” (The Joint Commission) Third in The Joint Commission’s series of animated Speak Up™ videos, this video is about taking medication safely. The cast of characters encounter everyday situations where they have to read instructions, ask for directions, and inspect labels, just like you do for medications to make sure you take them safely. Available in English and Spanish.
“Sentinel Event Alert, Issue 39: Preventing pediatric medication errors” (The Joint Commission) Joint Commission Sentinel Event Alert. This report shows that children are more prone than adults to medication errors and resulting harm and lists strategies and suggested actions to reduce medication errors.
“Speak Up: Help Avoid Mistakes With Your Medicines” (The Joint Commission) Joint Commission Patient Education Tools designed to help patients avoid mistakes with their medicines. Includes a brochure, poster, and wallet card with questions and answers. All are available in English and Spanish.
“Sentinel Event Alert, Issue 35: Using medication reconciliation to prevent errors” (The Joint Commission) Joint Commission Sentinel Event Alert. A report recommending the use of medication reconciliation to prevent medication errors. The process is defined, and strategies and actions are suggested for implementation.
“Sentinel Event Alert, Issue 23: Medication errors related to potentially dangerous abbreviations” (The Joint Commission) Joint Commission Sentinel Event Alert. Because medication safety and the identification, prevention and timely reporting of medication errors are of primary importance to the Joint Commission, this issue of Sentinel Event Alert specifically addresses medication errors related to the use of dangerous abbreviations and dose expressions used in prescribing medications.
“Sentinel Event Alert, Issue 19: Look-alike, sound-alike drug names” (The Joint Commission) This issue of The Joint Commission Sentinel Event Alert focuses specifically on medication errors resulting from confusing look-alike or sound-alike drug names and makes recommendations for minimizing risk and preventing potential errors.
“Sentinel Event Alert, Issue 16: Mix-up Leads to a Medication Error” (The Joint Commission) Joint Commission Sentinel Event Alert. In 1995, a 7-year-old boy died when he was injected with what was later discovered to be the wrong medication during routine, elective ear surgery. While this case is remembered for many reasons, most especially for the tragic and unnecessary loss of the young boy's life, it is also remembered within the health care community for the organization’s — Martin Memorial Medical Center in Stuart, FL — immediate response and openness in sharing with the boy's family and, later, other health care organizations, the steps taken following the event to prevent such medication administration errors from occurring in the future.
“Sentinel Event Alert, Issue 11: High-Alert Medications and Patient Safety” (The Joint Commission) Joint Commission Sentinel Event Alert. Medications that have the highest risk of causing injury when misused are known as high-alert medications. This report identifies the five most dangerous medications and lists risk factors and suggested strategies for increasing patient safety with respect to these high-alert medications.
“Medication Reconciliation” (Safer Healthcare Now!) This Web site provides kits, measures, mentor profiles, resources, and contacts to help caregivers reduce ADEs by following the Medication Reconciliation process.
“How-to Guide: Prevent Harm from High-Alert Medications” (IHI) This how-to guide describes key evidence-based care components for preventing harm from high-alert medications, describes how to implement these interventions, and recommends measures to gauge improvement.
“Anticoagulant Toolkit: Reducing Adverse Drug Events” (IHI) This toolkit outlines common risks and suggested safe practices and resources to reduce or eliminate risks that could lead to adverse drug events from anticoagulants such as unfractionated heparin, low molecular weight heparins, and warfarin.
“Reducing Anticoagulant-Related Adverse Events: Improving Hospital Safety Infrastructures and the Impact of Pharmacist Anticoagulation Services” (ASHP) The primary focus of this project was to reduce medication errors with anticoagulants to reduce harmful ADE. The secondary focus was to evaluate the impact of clinical pharmacists providing patient-centered anticoagulation therapy.
“Anticoagulation-Associated Adverse Drug Events” (AHRQ) This retrospective analysis of anticoagulant-related ADEs at an academic medical center identified the underlying cause of these events and found evidence that a large proportion should be preventable.
“Reduction in Anticoagulation-Related Adverse Drug Events Using a Trigger-Based Methodology” (National Institutes of Health, U.S. National Library of Medicine, National Center for Biotechnology Information) An article describing an initiative undertaken by Novant Health System to address warfarin-related adverse drug events (ADEs) using lab-based patient-specific International Normalized Ratio (INR) triggers and pharmacy-based patient-specific Vitamin K triggers.
Preventing Errors Relating to Commonly Used Anticoagulants (The Joint Commission) Joint Commission Sentinel Event Alert. These guidelines stress improving staff communication and access to information; implementing close pharmacy oversight and involvement; and enhancing patient education. Research shows there is a significant reduction in the risk of thromboembolic events and death among patients who manage their anticoagulation therapy compared with those who rely solely on their doctor to monitor their treatment.
“Adverse Drug Events in Intensive Care Units: A Cross-Sectional Study of Prevalence and Risk Factors” (American Association of Critical-Care Nurses, American Journal of Critical Care) An article assessing the characteristics of adverse drug events in patients admitted to an intensive care unit and determining the impact of severity of illness and nursing workload on the prevalence of the events.
“Clinical Excellence Series: Eliminating Adverse Drug Events at Ascension Health” (The Joint Commission, Journal on Quality and Patient Safety) Case study: Ascension Health’s efforts to eliminate ADEs utilizing the IHI Trigger Tool. In 2003, as part of its “Healthcare That Is Safe” strategy, Ascension Health sought to concentrate and expand the existing adverse drug event (ADE) reduction goals at each hospital to discover pockets of success in harm reduction that could be deployed to the other hospitals.
“Innovations Exchange: Medication Safety Reconciliation Toolkit” (AHRQ) An AHRQ “quality tool,” this Medication Reconciliation Toolkit helps hospitals establish and implement a standardized medication reconciliation process. The toolkit provides guidance, sample forms, and tips.
“Innovations Exchange: Medication Reconciliation Process Results in Anecdotal Reports of Improved Safety in Inpatient Setting” (AHRQ) Case study: Onslow Memorial Hospital implemented a medication reconciliation process, the cornerstone of which is a one-page structured form that nurses, physicians, and pharmacists use to list all medications taken by the patient at home.
“Innovations Exchange: Intravenous Infusion Safety Initiative Prevents Medication Errors, Leading to Cost Savings and High Nurse Satisfaction” (AHRQ) Case study: St. Joseph’s/Candler Health System implemented an Intravenous Infusion Safety Initiative to reduce the incidence of infusion administration errors. The program included standardization of medication nomenclature, concentration, and dosing; implementation of medication safety technology and monitoring systems; and expanding the role of respiratory therapists for patients on patient-controlled analgesia.
“Innovations Exchange: Collaborative Medication Reconciliation Significantly Reduces Errors and Readmissions in Patients Discharged to Nursing Homes” (AHRQ) Case study: Hennepin County Medical Center implemented a multidisciplinary medication reconciliation process for patients discharged to skilled nursing facilities, with the goal of ensuring that multiple reviews occur in a timely manner. The program virtually eliminated medication errors and reduced readmissions by nearly half, leading to significant cost savings.
“Innovations Exchange: Low-Tech Medication Reconciliation Process Emphasizing Standardized, Easy-to-Execute Roles Significantly Reduces Rate of Unreconciled Medications” (AHRQ) Case study: Contra Costa Health Services launched a medication reconciliation process at its county-owned hospital based on Institute for Healthcare Improvement concepts for redesigning work to achieve a high degree of reliability. Contra Costa Health Services uses a process in which providers, pharmacy, and nursing staff have standardized, easy-to-understand, and easy-to-execute roles related to medication reconciliation.

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