Adverse drug events (ADEs) present the single greatest risk of harm to patients in hospitals. Traditional efforts to detect ADEs have focused on voluntary reporting and tracking of errors. However, public health researchers have established that only 10 to 20 percent of errors are ever reported and, of those, 90 to 95 percent cause no harm to patients. Hospitals need a more effective way to identify events that do cause harm to patients, in order to select and test changes to reduce harm. Tracking high-alert ADEs per 1,000 medication doses over time is a useful way to tell if changes the team is making are improving the safety of the medication system.
Formula: The total number of ADEs related to a specific high-alert drug or class identified in a sample of patient records, divided by the total number of doses of the high-alert drug or class administered to those patients. Multiply the result by 1,000.
Reduce high-alert ADEs per 1,000 doses by 75 percent within 1 year.
Data Collection Plan
Select a high-alert drug or class for review. Every month, select a random sample of at least 20 closed patient records from those patients who received this high-alert drug or those in the class. Each patient should have had a minimum stay of two days. (Even better would be a weekly review of 10 records, with data reported as a monthly number of high alert ADEs per 1,000 doses.) Review the records, looking for "triggers" — certain medications, laboratory values, or events — that often provide clues that an ADE related to this high-alert drug or class has occurred. Investigate each trigger further to determine if a high-alert ADE did in fact occur. Do not include in the numerator any ADEs found that are related to other medications, although the details of every ADE should be reviewed. Obtain the total number of doses of the high-alert drug(s) administered for each patient from charge codes and units billed to the patient for medications.