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. And hypoglycemic events are the third most common cause of ADEs. WSHA is working with hospitals to reduce the rates of these three adverse drug events, in a collaborative effort to reduce harm and increase patient safety in our communities.

  • Inpatient Opioid Safety: In the hospital setting, 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. In the hospital setting, 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 from opioid utilization. WSHA is here to come alongside and support hospitals in their journey with safe pain management.
  • 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. Additionally, an estimated 10% of patients who were on insulin or a hypoglycemic agent had an ADE. Effective prevention of inpatient diabetes agent adverse events requires multidisciplinary coordination. A systematic approach is essential to promoting the safe and appropriate use of insulin and hypoglycemics in inpatient settings.
  • Anticoagulation Safety: Anticoagulants are the primary therapy for acute and long-term prevention for a number of thrombo-embolic disorders. Bleeding is the primary main concern with the use of anticoagulants. Thus, anticoagulation safety requires a very fine 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. WSHA supports hospitals in safe and effective anticoagulation therapy through a variety of resources and tools.

Strategies and Tools

General Resources Medical professional holding pills

Glycemic Control Boot Camp

Improving Glycemic Control in Non-Critical Care Units – Kristen Kulasa, MD

Improving Glycemic Control in Critical Care Units – Therese Franco, MD

Avoiding Hypoglycemia – Kirsten Kulasa, MD

Transition from Acute Care – Therese Franco, MD

Round Table and Group Discussion

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 – Updated 3.08.17

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