Eliminating ADE
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 |
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Clinical and Physician Co-Lead |
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Quality Leader |
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Content Specialists |
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Ancillary Department Representation |
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Frontline Staff Members |
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Patient/Family Representative |
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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
- 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
- **Insulin Infusion Order Set - A starting point to develop an Infusion Order Set
- **Anti-Coagulation Dosing & Management Guideline – A starting point to develop a Comprehensive Anti-Coagulation Program Guideline
- **Coumadin Monitoring – A starting point to develop a bedside coumadin monitoring tool
Communicate
- Safe Medication Use - Discussing medication safety with patients and families
Monitor
- Med Rec Event Review – Evaluate a medication reconciliation process
Sustain
- **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.