Measuring and Reducing Adverse Drug Events
Associated with High Risk Medications in Acute Care
Kathy Crea, Pharm.D., BCPS, Tom Sherrin, M.S., FASHP, Richard
Snow, D.O., M.P.H., Dave Morehead, M.D.
While medication errors and their prevention have been a
focus in previous years, recent efforts have focused on events
that cause harm to patients, such as adverse drug events (ADEs).
ADEs are common, with more than 770,000 people injured as
a result of drug therapy in hospitals each year. Aiming to
identify a subset of ADEs consistently, we modified the ADE
trigger tool used by Resar and colleagues. We used this tool
to identify opportunities for decreasing adverse drug events
and measure the success of improvement efforts.
Description of the Program
Previous studies have used a list of 24 triggers to identify
and facilitate review of charts to identify potential adverse
events in hospitalized patients. This project focused on three
classes of high risk medications and their seven associated
- Anticoagulants (PTT > 100, INR > 5, or administration
of vitamin K),
- Narcotics and sedatives (administration of naloxone or
- Insulin (serum glucose < 50 mg/dL or administration
of 50% dextrose injection).
Each of eight hospitals collected baseline data for three
months during which time all occurrences of these seven triggers
prompted a chart review to determine whether a related adverse
event had occurred. From these baseline data, each facility
chose one high risk class of medications as a focus for improvement
over the following 12-month period. A goal of a 10% reduction
was set, and this medication safety indicator was placed on
the OhioHealth “Balanced Scorecard.” This step
ensured accountability for success with the project.
Experience with the Program
Some of the interventions to reduce adverse events included
implementation of an anticoagulation dosing and monitoring
service for inpatients, elimination of range orders, failure
modes and effects analysis of the process for administering
insulin, and development of standardized physician order forms
and treatment algorithms. The project heightened awareness
of the medical staff, as well as the hospital staff, throughout
the system. It helped change the culture regarding the way
we look at adverse drug events in each facility, from the
highest level administrators to the health care staff on patient-care
After 11 months of data collection, results have shown a
reduction in ADEs in the selected medication classes from
an average rate of 61.3 adverse events/month across the system
to 34.0 adverse events/month, which represents a 45% relative
reduction. The estimated cost impact of decreasing adverse
events within just one class of high risk medications per
hospital over a one-year period is approximately $1.5 million
across the system. This was derived from the estimated post-event
hospital attributable to a preventable ADE of $4700 per admission
in 1997, which is likely higher in 2004.
The use of a modified trigger tool provided a consistent
method of identifying patients receiving high-risk medications
who have potentially experienced an adverse drug event for
further chart review. Providing a stable metric, accountability,
and process comparison at OhioHealth facilitated a 45% relative
reduction in ADEs within a selected high-risk medication class
in eight Ohio hospitals.
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