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January 2015 Excerpt



Adverse drug event (ADE)
An injury resulting from medical intervention related to a drug.

Potential adverse drug event (pADE)
Events where injury was possible but did not occur.

To Err is Human: Building A Safer Health System, Institute of Medicine.

A focus on ADEs can help reduce rehospitalizations

As part of its landmark Quality Chasm series, the Institute of Medicine reported that approximately 1.5 million preventable adverse drug events (ADEs) occur in the US each year.

Anticoagulants, opioids, and insulin are three of the most commonly implicated medications in ADEs. In fact, one study found that over half of emergent ADE-related hospitalizations of older Americans involved warfarin and hypoglycemics. Focusing ADE prevention efforts on these classes of medications will reduce harm to Medicare beneficiaries—and reduce both your community's hospitalization and readmission rates.

Your facility likely follows specific guidelines aimed at preventing common ADEs. In cases where a serious drug-related injury occurred or was narrowly avoided, a root-cause analysis and new preventive strategies were likely implemented. While safety programs such as these can make a strong impact, it is also important to track actual ADEs to evaluate program effectiveness.

Active ADE surveillance is critical. See our website for a starter set of resources, or contact one of our quality improvement consultants.