Adverse Drug Events

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 Meg Kilcup 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.

Planning An ADE Intervention

ADE Test of Change Template

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

Opioids Safety Action Bundle

Hypoglycemic Agents Safety Action Bundle

Michigan Opioid Safety Score (MOSS) Tool

National Action Plan for ADE

Glycemic Control Boot Camp Videos

Measuring Success

Report Writing Specifications: Adverse Drug Events Primary Measures

Anticoagulant Safety Measure Definition Sheet 

Hypoglycemic Agent Measure Definition Sheet 

Opioid Safety Measure Definition Sheet  

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

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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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