Medication Safety


Parntership for Patients Logo: WSHA and ASHNHA

On average, every patient admitted to a hospital is subject to at least one medication error per day. Two of the most common adverse outcomes due to adverse drug events (ADE) are warfarin overdose and inappropriate monitoring resulting in hemorrhage and opioid overdose resulting in respiratory depression. WSHA is working  to reduce rates of these two ADEs in addition to ADEs related to hypoglycemic agents.

Strategies and Tools

Medical professional holding pillsAll High Risk Medications Safety Action Bundle

Anticoagulants Safety Action Bundle

Opioids Safety Action Bundle

Hypoglycemic Agents Safety Action Bundle

Report Writing Specifications: Adverse Drug Events Primary Measures

Measuring Success

The preferred option for data submission on all three measures is the primary measure due to the higher clinical specificity. We ask those of you who have been submitting data continue to do so using your current data collection process. To assist those who are having challenges submitting this data, the WSHA ADE Advisory Group has added a second option for each of the three ADE measures.

 

Measures – Option 1

Anticoagulants Opioids Hypoglycemic Agents
Numerator: Number of patient events with an INR>5 after any warfarin administration (for patients cared for in an inpatient area> Number of patients (cared for in an inpatient area) who received naloxone <24 hours after any opioid administration related to over sedation. Number of BG* levels of <50 mg/dl after any hypoglycemic agent administration (for patients cared for in an inpatient area)
Denominator: Number of patients (cared for in an inpatient area) on warfarin Number of patients (cared for in an inpatient area) receiving opioids Number of patients (cared for in an inpatient area) receiving hypoglycemic agents (oral & insulin)

Measures – Option 2

Anticoagulants Opioids Hypoglycemic Agents
Numerator: Total number of INR>5 readings (for patients cared for in an inpatient area Total number of patients (cared for in an inpatient area) receiving naloxone after PCA administration Total number of BG* levels of <50 mg/dl (for patients cared for in an inpatient area)>
Denominator Total number of INR readings (for patients cared for in an inpatient area Total number of patients (cared for in an inpatient area) receiving PCA opioids Total patient days (excluding healthy newborns)

*BG = Blood Glucose

Primary ADE Measures*

Anticoagulant Usage Measure Definition SheetUpdated 3.8.17

Opioid Usage Measure Definition Sheet Updated 4.3.17

Hypoglycemic Agent Measure Definition Sheet Updated 4.3.17
*Report Writing Specifications for Primary ADE Measures РUpdated 3.08.17

Option 2 ADE Measures – for hospitals who are unable to collect and submit Primary Measures

Option 2 Anticoagulant Usage INR Measure Definition SheetUpdated 3.08.17

Option 2 Patient Controlled Analgesia (PCA) Opioid Measure Definition Sheet Updated 4.3.17

Option 2 Hypoglycemic Agent Usage Measure Definition Sheet Updated 4.3.17

For information about the availability of auxiliary aids and services, please visit:
http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html

Affiliates

Contact Us

Washington State Hospital Association
999 Third Avenue
Suite 1400
Seattle, WA 98104

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206.281.7211 phone
206.283.6122 fax

info@wsha.org

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