Importance: An ADE is an injury to a patient resulting from a medication intervention, which can occur in any health care setting (Nebecker et al., 2004). A study of Medicare beneficiaries by the U.S. Department of Health and Human Services found that 30 percent of inpatients experienced an ADE (OIG, 2010). The Agency for Healthcare Research and Quality (AHRQ) estimated that drug-related adverse events occurred in nearly 1.9 million inpatient stays, which include events which caused little to no harm to those resulting in death (Lucado et al., 2011). Listen to Leah's story to learn more about the impact of ADEs on patients and their families. The Office of Disease Prevention and Health Promotion (ODPHP) released "The National Action Plan for ADE Prevention" in October 2014; the report focuses efforts on the group of ADEs that are: common, clinically significant, preventable and measurable; resulting from high-priority drug classes; and occurring largely in high-risk populations (ODPHP, 2014). The high-priority drug classes are also referred to as high alert medications (HAMs) (Smetzer et al., 2003). The Joint Commission defines HAMs as more likely to be associated with harm than other drugs – they cause harm more frequently, the harm they produce is likely to be more serious and they have the highest risk of causing injury when misused (The Joint Commission, 2007). For the purposes of the HIIN project and the ADE Action Plan, the drug classes of focus include: 1) anticoagulants, 2) diabetes agents and 3) opioids.
Accomplishments: From 2011 to 2014, the AHA/HRET HEN prevented an estimated 8,155 ADEs with an estimated cost savings of over $24 million. From September 2015 to September 2016, the AHA/HRET HEN 2.0 prevented an estimated 15, 611 ADEs with an estimated cost savings of over $78 million.
PfP Goal: By September 27, 2018, a 20 percent reduction in Adverse Drug Events.
ADE Change Package
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