This HQI toolkit will assist hospitals in measuring adverse drug events, identifying and engaging key stakeholders, providing harm elimination tools that work, and learning through the success of other hospitals.

This toolkit is divided into five sections, which will open individually by clicking on each green tab below (blue indicates the open tab):

• What to Measure, listing the outcome and process measures focused upon in this toolkit;
• Key Improvement Team Members, providing a basic list of who should be involved;
• Tools that Work, a compilation of proven tools and methods;
• Success Stories, highlighting the success of hospitals that used the tools within this toolkit; and
• Additional Resources, websites beyond this toolkit that have proven resourceful.

A link to the toolkit evaluation form is also provided in order to receive feedback.

What to Measure

Refer to the HRET-HEN website “AHA/HRET Comprehensive Data System Encyclopedia of Measures” for the full list of improvement measures and additional information.

• EOM-ADE-12: Excessive Anticoagulation with Warfarin – Inpatients
• EOM-ADE-13: Hypoglycemia in Inpatients Receiving Insulin
• EOM-ADE-111: ADEs due to opioids

Key Improvement Team Members

There are many people that should have an interest in eliminating ADEs within a hospital. Provided below is a minimal list of stakeholders who should be required as Team Members. Additional inclusions at hospital discretion are suggested.

Key Members	Role
Executive Sponsor	Helps the team prioritize improvement efforts Helps the team navigate organizational bureaucracy Ensures the team has resources to fix problems Makes rounds and meets regularly with members of health care team in the care areas
Clinical and Physician Co-Lead	Serves as role model for team activities Meets with team regularly Participates in senior executive partnership meetings Communicates with physician group and clinical leadership as needed Assists with implementation of interventions
Quality Leader	Supports team activities Ensures results of activities are shared with staff Assigns project leaders to interventions and tracks progress
Content Specialists	Provide their expertise on the harm area to team
Ancillary Department Representation	Provide their expertise on the involvement of their service regarding the harm area Obtains ancillary staff feedback to initiatives
Frontline Staff Members	Encourages unit staff involvement Obtains staff feedback Manages documentation of activities
Patient/Family Representative	Provide the voice of the patient/family Review all patient/family education

Tools that Work

Tools that work are key resources to reduce ADEs.  Hospitals noticing an increase in ADEs should focus on the tools with “**”. Hospitals successful in reducing ADEs but not quite reaching Aim should focus on the additional tools provided.

These example tools have been compiled by HQI staff, and are intended for consideration in hospitals as current practices are evaluated and specific programs are developed. These are examples, not fixed protocols that must be followed, nor are they entirely inclusive or exclusive of all methods of reasonable care that can obtain/produce the same results.

Assess

1. High Alert Medication Policy includes Warfarin, Insulin and Opioids: ISMP High Alert Medications – Verify a policy is in place to address all High Alert Medications

Act

2. **Insulin Infusion Order Set - A starting point to develop an Infusion Order Set
3. **Anti-Coagulation Dosing & Management Guideline – A starting point to develop a Comprehensive Anti-Coagulation Program Guideline
4. **Coumadin Monitoring – A starting point to develop a bedside coumadin monitoring tool

Communicate

5. Safe Medication Use - Discussing medication safety with patients and families

Monitor

6. Med Rec Event Review – Evaluate a medication reconciliation process 

Sustain

7. **Good Catch Awards – How to set up a Good Catch Program to engage frontline staff in medication safety. Award Template also provided.

Success Stories

• Salinas Valley Memorial Healthcare System  (Tools 1, 3, 5, and 7)
• Fresno Heart and Surgical Hospital  (Tools 1, 2, 5, 6, and 7)
• San Gorgonio Memorial Hospital (Tools 1, 3, 4, 5, and 7)

Additional Resources

ADE Top Ten Checklist
A list of the top ten adverse drug event interventions collated by the Partnerships for Patients

Using Smart Pumps to Reduce ADEs
This 2013 presentation includes effective use of smart pumps to reduce medication errors and legal ramifications for clinical staff if smart pump technology is not used

Eliminate Hypoglycemia
(Presentation to the California Society of Health System Pharmacists)
This 2013 presentation demonstrates the improvement activities implemented by a California Hospital to reduce hypoglycemia adverse events

Achieving Breakthrough Improvement in Reducing Adverse Drug Events
A comprehensive guide to reducing adverse drug events by showing how organizations applied  change concepts to different parts of the medication system

HRET ADE Change Package
A comprehensive toolkit regarding adverse drug event prevention, including background information, prevention strategies, measurement processes and tools for implementation

Road Map to a Medication Safety Program
Evidence-based recommendations/standards for hospitals in the development of a comprehensive medication safety program.

Evaluate this Toolkit

Your feedback of toolkit is important to HQI. Based upon your input, we can determine which tools to keep, remove, replace, or modify to better meet your needs in harm elimination. We welcome and encourage your engagement in providing feedback by completing a tools evaluation.

Evaluate this toolkit