On average, every patient admitted to a hospital is subject to at least one medication error per day. The most common adverse outcomes due to adverse drug events (ADE) are warfarin overdose and inappropriate monitoring resulting in hemorrhage, as well as opioid overdose resulting in respiratory depression. Hypoglycemic events are the third-most common cause of ADEs. WSHA is working in a collaborative effort with hospitals to reduce the rates of these three adverse drug events to reduce harm and increase patient safety in our communities.
- Inpatient Opioid Safety: In the hospital, addressing unintentional opioid overdose (causing respiratory depression and over-sedation) is a high priority to prevent morbidity and mortality. Opioid overdoses represent a tremendous public health burden that is potentially preventable to measurable prevention efforts. For inpatients, this includes implementing safe and appropriate pain management therapies (minimizing opioid use when possible) and utilizing a risk assessment tool to ensure patients are not at risk for over-sedation or respiratory depression.
- Glycemic Control: Nearly all cases of hypoglycemia are considered preventable. In most hospital settings, teams have protocols for the reversal of hypoglycemia, but not for the prevention of it. In a nationally representative sample, clinically significant hypoglycemia has been identified in approximately 2% of ICU patients and 2 – 5% of inpatients with diabetes. Effective prevention of inpatient diabetes agent adverse events requires multidisciplinary coordination.
- Anticoagulation Safety: Anticoagulants are the primary therapy for acute and long-term prevention for thrombo-embolic disorders. Bleeding is the primary concern with anticoagulants. Thus, anticoagulation safety requires a careful balance of thrombotic and hemorrhagic risks and is influenced by a variety of factors, such as patient age, comorbidities, concurrent medications, diet and pharmacogenetics. For warfarin, bleeding frequency has been an estimated 15 – 20% per year, and life-threatening or fatal bleeding events are estimated at 1 – 3% per year.
Getting Started
The best way to get started is by printing your ADE data from QBS or the Patient Safety Comparison Report. Contact Tina Seery if you don’t have access to your data. Then gather your team, identify areas with most opportunity for improvement and get started using the guides below.
ADE Anticoagulant Safety Checklist
ADE Hypoglycemic Safety Checklist
ADE Opioid Overdose Safety Checklist
Resources
Report Writing Specifications: Adverse Drug Events Primary Measures
All High-Risk Medications Safety Action Bundle
Anticoagulants Safety Action Bundle
Hypoglycemic Agents Safety Action Bundle
Michigan Opioid Safety Score (MOSS) Tool
Glycemic Control Boot Camp Videos
Measuring Success
Report Writing Specifications: Adverse Drug Events Primary Measures
Anticoagulant Safety Measure Definition Sheet
