Improvement Report: Reducing ADEs per 1,000 Doses

Order of St. Francis — St. Joseph Medical Center
Bloomington, Illinois, USA



Kathy Haig, RN, Director of Quality Resource Management, Risk Manager, Patient Safety Officer
Larry Wills, Senior Assistant Administrator Hospital Operations
Paul Pedersen, MD, Medical Director
Cindy Patterson, RN, BSN, Nursing Operations Manager
Michael Novario, RPH, Director of Pharmacy
Robert Hoy, PharmD, Clinical Pharmacist
Sue Doolin, RN, BSN, Care Coordinator



Decrease the number of adverse drug events (ADEs) per 1,000 doses by 50 percent



ADEs per 1,000 Doses



  • Extended non-punitive response from medication events to all medical events.
  • Developed an Organizational Patient Safety Plan.
  • Incorporated Patient Safety into orientation, annual education.
  • Added an "ADE Hotline" and saw a ten-fold increase in calls to the hotline. We then extended use of the hotline to medical group (physician) offices.
  • Conducted cultural surveys every six months.
  • Implemented weekly Administrative Safety Rounds and rounds by the Patient Safety Officer.
  • Reported monthly measure data to the Quality Council on patient safety issues. Patient Safety is also a standing agenda item for each Medical Staff Department/Committee/Section.
  • Implemented use of a single heparin/enoxaparin nomogram.
  • Developed pre-printed heparin/enoxaparin orders based on the nomogram.
  • Implemented a pharmacy based Coumadin dosing protocol.
  • Developed a single form that could be used for reconciliation of medications at both admission and discharge. The form included physician medication orders so that everything would be in one place.
  • Separated sound alike-look alike medications in the Pharmacy and on the nursing units.
  • Developed Patient Safety Brochures and placed them in waiting areas, physician offices, Urgent Care, Emergency Department, plus distributed to patients on admission
  • Implemented daily rounds by a clinical pharmacist who compares medication orders to lab values.
  • Added a process where pharmacy technicians pick up medications from discharged patients within two hours of patient discharge using a labeled "baggie."
  • Standardized our intravenous drip concentrations.
  • Decreased the amount of stock medications kept on patient care units.
  • Eliminated use of high-risk abbreviations.
  • Changed process for non-standard doses so that all are prepared and packaged in the pharmacy.
  • Initiated Safety Briefings with feedback to employees of actions taken on reported safety concerns.
  • Initiated a Patient Controlled Analgesia (PCA) Standing Order set as well as standardized order sets for Congestive Heart Failure (CHF)/Pneumonia and Chronic Obstructive Pulmonary Disease (COPD).
  • Developed a radiology process to prevent/address contrast extravasations.
  • Initiated Perioperative Beta Blocker Protocol.
  • Installed a Sure Med machine in the Operating Room (OR) for narcotics.
  • Standardized epidural pumps and use yellow colored tubing with these pumps.





Summary of Results / Lessons Learned / Next Steps

Implementing procedures for reconciliation has been the most significant change in reducing ADEs and we now feel that it is part of our culture. Physician support has been instrumental in completing reconciliation.  Improvement ideas have been readily shared with competitor hospitals at the request of physicians, as OSF St. Joseph believes that there are no boundaries or competition when it comes to patient safety.

  • Involve the right people. It is important for the "players" or those directly involved in the process to have a voice. This helps in identifying problem areas and to more quickly obtain buy-in.
  • Use rapid cycles of change. This eliminates wasted time in researching, planning, developing, education, implementing, etc. without knowing if the process truly works.
  • Make the process as simple as possible. This helps to make it a win-win situation for both the patient and staff.
  • Share the success. Print graphs, make posters, buy pizza, take pictures, etc. to celebrate your accomplishments.
  • Don’t be afraid of failure. You can learn as much from a failed test as you can from a successful one.
  • Don’t reinvent the wheel. If another organization has used a strategy, idea or form that works, adopt it.
  • Communicate, communicate, communicate! Get the word out to everyone. It helps to use different vehicles to communicate: meetings, hospital publications, flyers, etc.
  • Gain a strong commitment from senior leadership.
  • Their support is crucial. When they round to different units, have them ask the staff about their role in reducing events, what they have identified that could cause harm, or what they have to do in their jobs to prevent harm.

Contact Information

Kathy Haig
Director of Quality Resource Management/Risk

See the team's June 2003 presentation at the Institute for Healthcare Improvement's IMPACT Learning Session.

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