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 the percentage of admissions with an ADE over time is a useful way to tell if changes are leading to improvement.
Formula: The total number patients identified as having experienced any ADE from a sample of patient records, divided by the total number of records in the sample. Multiply the result by 100 to express as a percentage.
Decrease the percentage of admissions with an ADE by 75 percent within 1 year.
Data Collection Plan
Every month, select a random sample of at least 20 closed patient records, each with a minimum stay of two days. (Even better would be a weekly review of 10 records, with data reported as a monthly number of ADEs per admission.) Review the records, looking for "triggers" — certain medications, laboratory values, or events — that often provide clues that an ADE has occurred. Investigate each trigger further to determine if an ADE did in fact occur. Patients who experienced multiple ADEs should be counted only once in the numerator, although the details of every ADE should be reviewed.