ADE Final May 2012
Category
Core
Core
Core
Core
Core
Core
Core/
Supporting
Title
“How-to Guide: Prevent Harm from High-Alert Medications”
(IHI)
Source http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePre ventHarmfromHighAlertMedications.aspx
“Reducing and Preventing
Adverse Drug Events to
Decrease Hospital Costs” (U.S.
Department of Health &
Human Services, Agency for
Healthcare Research and
Quality [AHRQ])
“NCC MERP” (The National
Coordinating Council for
Medication Error Reporting and Prevention) http://www.ahrq.gov/qual/aderia/aderia.htm http://www.nccmerp.org/
Description
This how-to guide describes key evidence-based care components for preventing harm from high-alert medications, describes how to implement these interventions, and recommends measures to gauge improvement.
Many ADE injuries and resulting hospital costs can be reduced if hospitals make changes to their systems for preventing and detecting ADEs. Some approaches found to be successful are summarized in this Web site.
“Adverse Drug Reaction
Surveillance: Practical
Methods for Developing a
Successful Monitoring
Program” (Medscape from
WebMD)
“Medication Reconciliation”
(Safer Healthcare Now!)
“Anticoagulant Toolkit:
Reducing Adverse Drug
Events” (IHI)
“ISMP” (Institute for Safe
Medication Practices) http://www.medscape.com/viewarticle/408575 http://www.saferhealthcarenow.ca/EN/Interventions/medr ec/Pages/default.aspx http://www.ihi.org/knowledge/Pages/Tools/AnticoagulantT oolkitReducingADEs.aspx http://www.ismp.org/
Founded by the United States Pharmacopeia, the mission of
NCC MERP is to maximize the safe use of medications and to increase awareness of medication errors through open communication, increased reporting, and promotion of medication error prevention strategies.
Article. Barriers to improved reporting of adverse drug events (ADEs) are evaluated and mechanisms to overcome these barriers are presented. The impact of ADR surveillance on the evaluation and modification of the medication-use system at Northeast Health to improve patient quality of care is described.
This Web site provides kits, measures, mentor profiles, resources, and contacts to help caregivers reduce ADEs by following the Medication Reconciliation process.
This toolkit outlines common risks and suggested safe practices and resources to reduce or eliminate risks that could lead to adverse drug events from anticoagulants such as unfractionated heparin, low molecular weight heparins, and warfarin.
A comprehensive Web site with medication safety tools, reports, resources, products, alerts, and videos.

ADE Final May 2012
Category
Enhanced
Enhanced
Enhanced -
Pedi
“How-to Guide: Prevent
Adverse Drug Events
(Medication Reconciliation) —
Pediatric Supplement” (IHI)
HPH
Supporting
Title
“How-to Guide: Prevent
Adverse Drug Events
(Medication Reconciliation)”
(Institute for Healthcare
Improvement [IHI])
“Trigger Tool for Measuring
Adverse Drug Events” (IHI)
“MATCH Medication
Reconciliation Toolkit” (IHI)
“Preventing Adverse Drug
Events (Medication
Reconciliation): Patient and
Family Fact Sheet” (IHI)
Source http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePre ventAdverseDrugEvents.aspx http://www.ihi.org/knowledge/Pages/Tools/TriggerToolfor
MeasuringAdverseDrugEvents.aspx http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePre ventAdverseDrugEventsPediatricSupplement.aspx http://www.ihi.org/knowledge/Pages/Tools/MATCHMedicat ionReconciliationToolkit.aspx http://www.ihi.org/knowledge/Pages/Tools/PreventingADEs
PatientandFamilyFactSheet.aspx
Description
This how-to guide describes key evidence-based care components to prevent adverse drug events (ADEs) by implementing medication reconciliation at all transitions in care (at admission, transfer, and discharge), describes how to implement these interventions, and recommends measures to gauge improvement.
This tool includes a list of known ADE triggers and instructions for measuring the number and degree of harmful medication events. The tool provides instructions and forms for collecting the data you need to measure ADEs per 1,000 Doses and Percent of Admissions with an ADE.
This how-to guide specifically tailored for pediatrics describes key evidence-based care components to prevent adverse drug events (ADEs) by implementing medication reconciliation at all transitions in care (at admission, transfer, and discharge), describes how to implement these interventions, and recommends measures to gauge improvement.
The medication reconciliation initiative at Northwestern
Memorial Hospital, called MATCH, included development of a toolkit to help hospital and outpatient practice staff.
This resource for patients and families provides an overview of how to prevent adverse drug events by reconciling medications at all transitions in care (at admission, transfer, and discharge). Available in English and Spanish.
Supporting
Supporting
“Reducing Medication Errors”
(Massachusetts Coalition for the Prevention of Medical
Errors)
“Preventable Adverse Drug
Reactions: A Focus on Drug
Interactions” (U.S.
Department of Health & http://www.macoalition.org/reducing_medication_errors.sh
tml
A Web site listing initiatives to reduce medication errors in anticoagulation medicine, ambulatory settings, acute care facilities, long-term care facilities, and consumer safety. http://www.fda.gov/drugs/developmentapprovalprocess/de velopmentresources/druginteractionslabeling/ucm110632.h
tm
This learning module was developed based on a needs survey sent to all third-year medicine clerkship directors and all medicine residency program directors in the United
States.

ADE Final May 2012
Category Title
Human Services, U.S. Food and
Drug Administration [FDA])
Source Description
Supporting
“Safe Use Initiative:
Collaborating to Reduce
Preventable Harm from
Medications” (FDA)
Supporting
Supporting
“Incidence of Adverse Drug
Events and Potential Adverse
Drug Events: Implications for
Prevention” (Journal of the
American Medical Association)
“MedWatch: The FDA Safety
Information and Adverse
Event Reporting Program”
(FDA)
“Adverse Event Reporting
System (AERS)” (FDA) http://ptsafetyresearch.org/journal%20articles/Original%20
021.pdf http://www.fda.gov/Safety/MedWatch/default.htm http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryI nformation/Surveillance/AdverseDrugEffects/default.htm
Supporting
Supporting
“Preventing Medication
Errors: Quality Chasm Series”
(Institute of Medicine of the
National Academies) http://www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/def ault.htm
The mission of the Safe Use Initiative is to create and facilitate public and private collaborations within the healthcare community. The goal of the Safe Use Initiative is to reduce preventable harm by identifying specific, preventable medication risks and developing, implementing and evaluating cross-sector interventions with partners who are committed to safe medication use.
Article. Assessment of the incidence and preventability of adverse drug events (ADEs) and potential ADEs, with analysis of preventable events to develop prevention strategies. http://www.iom.edu/Reports/2006/Preventing-Medication-
Errors-Quality-Chasm-Series.aspx
FDA gateway for clinically important safety information and for reporting serious problems with human medical products.
The Adverse Event Reporting System (AERS) is a computerized information database designed to support the
FDA’s post-marketing safety surveillance program for all approved drug and therapeutic biologic products. The FDA uses AERS to monitor for new adverse events and medication errors that might occur with these marketed products.
The Institute of Medicine Report Preventing Medication
Errors puts forward a national agenda for reducing medication errors based on estimates of the incidence and cost of such errors and evidence on the efficacy of various prevention strategies.

ADE Final May 2012
Category
Supporting
Supporting
Supporting
Title
Medication-Related Adverse
Outcomes in U.S. Hospitals and Emergency Departments,
2008 (AHRQ, Healthcare Cost and Utilization Project)
Hospital Incident Reporting
Systems Do Not Capture Most
Patient Harm (U.S.
Department of Health &
Human Services, Office of
Inspector General)
“WHO Programme for
International Drug
Monitoring” (World Health
Organization)
Supporting
Supporting
“Sentinel Event Alert, Issue 39:
Preventing pediatric medication errors” (The Joint
Commission)
“Speak Up: Help Avoid
Mistakes With Your
Medicines” (The Joint
Source http://www.jointcommission.org/sentinel_event_alert_issue
_39_preventing_pediatric_medication_errors/ http://www.jointcommission.org/Speak_Up__Help_Avoid_
Mistakes_With_Your_Medicines/
Description http://www.hcup-us.ahrq.gov/reports/statbriefs/sb109.pdf This AHRQ Statistical Brief presents data from the Healthcare
Cost and Utilization Project (HCUP) on medication - or drugrelated adverse outcomes that were seen in hospitals in
2008. In addition, data are also presented on treat-andrelease emergency department visits. http://oig.hhs.gov/oei/reports/oei-06-09-00091.asp A summary of the January 2012 Office of the Inspector
General (OIG) report on the state of hospital incident reporting. The conclusion (concurred with by AHRQ and
CMS) is that strengthening hospital reporting systems and practices is essential. http://www.who.int/medicines/areas/quality_safety/safety_ efficacy/National_PV_Centres_Map/en/index.html
The aims of the WHO Pharmacovigilence Programme are to enhance patient care and patient safety in relation to the use of medicines, and to support public health programs by providing reliable, balanced information for the effective assessment of the risk-benefit profile of medicines.
A database and resource gateway to help patients use medicines safely and effectively.
Supporting
Supporting
“Safe Medication: Your
Trusted Source of Drug
Information” (American
Society of Health-System
Pharmacists [ASHP])
“Videos and Podcasts — Speak
Up: Take Medication Safely”
(The Joint Commission) http://www.safemedication.com/ http://www.jointcommission.org/multimedia/speak-up-take-medication-safely/
Third in The Joint Commission’s series of animated Speak
Up™ videos, this one is about taking medication safely. The cast of characters encounter everyday situations where they have to read instructions, ask for directions, and inspect labels, just like you do for medications to make sure you take them safely. Available in English and Spanish.
Joint Commission Sentinel Event Alert. A report showing that children are more prone than adults to medication errors and resulting harm, and listing strategies and suggested actions to reduce medication errors.
Joint Commission Patient Education Tools designed to help patients avoid mistakes with their medicines. Brochure, poster, and wallet card with questions and answers. All are

ADE Final May 2012
Category
Commission)
Title Source Description available in English and Spanish.
Supporting
Supporting
Supporting
Supporting
Supporting
“Sentinel Event Alert, Issue 35:
Using medication reconciliation to prevent errors” (The Joint Commission)
“Sentinel Event Alert, Issue 23:
Medication errors related to potentially dangerous abbreviations” (The Joint
Commission)
“Sentinel Event Alert, Issue 19:
Look-alike, sound-alike drug names” (The Joint
Commission)
“Sentinel Event Alert, Issue 16:
Mix-up Leads to a Medication
Error” (The Joint Commission) http://www.jointcommission.org/sentinel_event_alert_issue
_16_mix-up_leads_to_a_medication_error/
“Sentinel Event Alert, Issue 11:
High-Alert Medications and
Patient Safety” (The Joint
Commission) http://www.jointcommission.org/sentinel_event_alert_issue
_35_using_medication_reconciliation_to_prevent_errors/ http://www.jointcommission.org/sentinel_event_alert_issue
_23_medication_errors_related_to_potentially_dangerous_ abbreviations/ http://www.jointcommission.org/sentinel_event_alert_issue
_19_look-alike_sound-alike_drug_names/ http://www.jointcommission.org/sentinel_event_alert_issue
_11_high-alert_medications_and_patient_safety/
Joint Commission Sentinel Event Alert. A report recommending the use of medication reconciliation to prevent medication errors. The process is defined, and strategies and actions are suggested for implementation.
Joint Commission Sentinel Event Alert. Because medication safety and the identification, prevention and timely reporting of medication errors are of primary importance to the Joint Commission, this issue of Sentinel Event Alert specifically addresses medication errors related to the use of dangerous abbreviations and dose expressions used in prescribing medications.
This issue of The Joint Commission Sentinel Event Alert focuses specifically on medication errors resulting from confusing look-alike or sound-alike drug names and makes recommendations for minimizing risk and preventing potential errors.
Joint Commission Sentinel Event Alert. In 1995, a 7-year-old boy died when he was injected with what was later discovered to be the wrong medication during routine, elective ear surgery. While this case is remembered for many reasons, most especially for the tragic and unnecessary loss of the young boy's life, it is also remembered within the health care community for the organization’s — Martin Memorial Medical Center in Stuart,
FL — immediate response and openness in sharing with the boy's family and, later, other health care organizations, the steps taken following the event to prevent such medication administration errors from occurring in the future
Joint Commission Sentinel Event Alert. Medications that have the highest risk of causing injury when misused are known as high-alert medications. This report identifies the five most dangerous, and lists risk factors and suggested

ADE Final May 2012
Category Title Source Description strategies for increasing patient safety with respect to these high-alert medications.
Supporting
Supporting
“Reducing Anticoagulant-
Related Adverse Events:
Improving Hospital Safety
Infrastructures and the Impact of Pharmacist Anticoagulation
Services” (ASHP)
“Anticoagulation-Associated
Adverse Drug Events” (AHRQ) http://www.ashpadvantage.com/bestpractices/2006_papers
/2006_mcm_posters/Kentucky_Rv2.pdf http://psnet.ahrq.gov/resource.aspx?resourceID=23620
Supporting
Supporting
“ Reduction in Anticoagulation-
Related Adverse Drug Events
Using a Trigger-Based
Methodology” (National
Institutes of Health,
,
)
Preventing Errors Relating to
Commonly Used
Anticoagulants (The Joint
Commission)
Supporting
“Adverse Drug Events in
Intensive Care Units: A Cross-
Sectional Study of Prevalence and Risk Factors” (American http://www.ncbi.nlm.nih.gov/pubmed/15999959 http://www.jointcommission.org/assets/1/18/SEA_41.PDF http://ajcc.aacnjournals.org/content/20/6/e131.full
The primary focus of this project was to reduce medication errors with anticoagulants to reduce harmful ADE. The secondary focus was to evaluate the impact of clinical pharmacists providing patient-centered anticoagulation therapy.
This retrospective analysis of anticoagulant-related ADEs at an academic medical center identified the underlying cause of these events and found evidence that a large proportion should be preventable.
An article describing an initiative undertaken by Novant
Health System to address warfarin-related adverse drug events (ADEs) using lab-based patient-specific International
Normalized Ratio (INR) triggers and pharmacy-based patientspecific Vitamin K triggers.
Joint Commission Sentinel Event Alert. These guidelines stress improving staff communication and access to information; implementing close pharmacy oversight and involvement; and enhancing patient education. Research shows there is a significant reduction in the risk of thromboembolic events and death among patients who manage their anticoagulation therapy compared with those who rely solely on their doctor to monitor their treatment.
An article assessing the characteristics of adverse drug events in patients admitted to an intensive care unit and determine the impact of severity of illness and nursing workload on the prevalence of the events.

ADE Final May 2012
Category Title
Association of Critical-Care
Nurses, American Journal of
Critical Care)
Source Description
Supporting
“Clinical Excellence Series:
Eliminating Adverse Drug
Events at Ascension Health”
(The Joint Commission, Journal
on Quality and Patient Safety) http://www.ascensionhealth.org/assets/docs/EliminatingAd verseDrugEventsatAscensionHealth.pdf
Supporting
Supporting
Supporting
Supporting
“Innovations Exchange:
Medication Safety
Reconciliation Toolkit” (AHRQ)
“Innovations Exchange:
Medication Reconciliation
Process Results in Anecdotal
Reports of Improved Safety in
Inpatient Setting” (AHRQ)
“Innovations Exchange:
Intravenous Infusion Safety
Initiative Prevents Medication
Errors, Leading to Cost Savings and High Nurse Satisfaction”
(AHRQ)
“Innovations Exchange:
Collaborative Medication
Reconciliation Significantly
Reduces Errors and
Readmissions in Patients
Discharged to Nursing Homes”
(AHRQ) http://www.innovations.ahrq.gov/content.aspx?id=2173 http://www.innovations.ahrq.gov/content.aspx?id=1704 http://www.innovations.ahrq.gov/content.aspx?id=2375 http://www.innovations.ahrq.gov/content.aspx?id=3111
Case study: Ascension Health’s efforts to eliminate ADEs utilizing the IHI Trigger Tool. In 2003, as part of its
“Healthcare That Is Safe” strategy, Ascension Health sought to concentrate and expand the existing adverse drug event
(ADE) reduction goals at each hospital to discover pockets of success in harm reduction that could be deployed to the other hospitals.
An AHRQ “quality tool,” this Medication Reconciliation
Toolkit helps hospitals establish and implement a standardized medication reconciliation process. The toolkit provides guidance, sample forms, and tips.
Case study: Onslow Memorial Hospital implemented a medication reconciliation process, the cornerstone of which is a one-page structured form that nurses, physicians, and pharmacists use to list all medications taken by the patient at home.
Case study: St. Joseph’s/Candler Health System implemented an Intravenous Infusion Safety Initiative to reduce the incidence of infusion administration errors. The program included standardization of medication nomenclature, concentration, and dosing; implementation of medication safety technology and monitoring systems; and expanding the role of respiratory therapists for patients on patientcontrolled analgesia.
Case study: Hennepin County Medical Center implemented a multidisciplinary medication reconciliation process for patients discharged to skilled nursing facilities, with the goal of ensuring that multiple reviews occur in a timely manner.
The program virtually eliminated medication errors and reduced readmissions by nearly half, leading to significant cost savings.

ADE Final May 2012
Category
Supporting
Title
“Innovations Exchange: Low-
Tech Medication
Reconciliation Process
Emphasizing Standardized,
Easy-to-Execute Roles
Significantly Reduces Rate of
Unreconciled Medications”
(AHRQ)
Source http://www.innovations.ahrq.gov/content.aspx?id=2082
Description
Case study: Contra Costa Health Services launched a medication reconciliation process at its county-owned hospital based on Institute for Healthcare Improvement concepts for redesigning work to achieve a high degree of reliability. Contra Costa Health Services uses a process in which providers, pharmacy, and nursing staff have standardized, easy-to-understand, and easy-to-execute roles related to medication reconciliation.