Reducing Adverse Drug Events (ADEs)

Reducing Adverse Drug Events (ADEs)

Reducing Medication-Related Harm

Improving Individual Patient Care Overview
Adverse events secondary to medication therapy are the most common type of health care-associated adverse event.

There is a growing awareness that many of these adverse events are due to medication errors, making adverse drug events (ADEs) a major source of potentially preventable patient harm. ADEs disproportionately affect patients over the age of 65 across all settings including in hospital, ambulatory care and long-term care facilities.

Adverse Drug Events in the Community

Outpatient providers who join in the QIO Program’s adverse drug event (ADE) initiative will be contributing to a national goal of reducing ADEs in 265,000 lives per year. In several communities in every state and territory, QIOs are bringing together clinical pharmacists, primary care clinics, and other providers that care for older patients with multiple chronic conditions who are at risk for the potentially negative consequences of polypharmacy. The initiative is modeled on the Health Resources and Services Administration’s successful Patient Safety and Clinical Pharmacy Services (PSPC) Collaborative. Participants can expect to benefit from participation in a statewide LAN, access to evidence-based tools for assessing pharmacy processes and implementing safer practices, support for rapid-cycle improvement, and strategies for spreading success within their community.

Qsource is partnering with organizations currently participating in the Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) Breakthrough Collaborative(s). We will help lead two to three multidisciplinary community teams comprised of the following organizations:

  • Local clinical pharmacy representation
  • Clinicians from the multiple settings utilized by the targeted patient groups (e.g. hospitals, nursing homes, primary care clinics, specialty clinics, federally funded clinics, etc)
  • Clinic and/or hospital senior leadership
  • Patient and/or patient advocacy representation
We will identify and monitor patient groups for:
  • Persistently out-of-control health status based on established clinical health measures and standards such as HgA1c (glucose monitoring) and International Normalized Ratio (INR) (a lab test related to anticoagulation therapy management).
  • High medication risk due to multiple medications, multiple providers and/or inadequate medication use systems.
Specifically, beneficiaries shall meet one of the following criteria:
  • Are high-risk patients who have 5 or more chronic conditions and/or who take 8 or more medications on at least a weekly basis and/or
  • Are evaluated by 2 or more providers and/or
  • Take the anticoagulant Warfarin on a regular basis and/or
  • Take short-acting or long-acting antipsychotics of any class and/or
  • Take hypoglycemic medication for diabetes mellitus

Qsource will utilize the tools and interventions available in the PSPC Collaborative to accomplish our goals in Tennessee.

Click here to download the PSPC Change Package, developed by HRSA:

Click here for the ADE Resource Guide

Click here to enter (HC), a web-based knowledge management system that provides multiple means for the healthcare quality improvement community to share knowledge and contribute to each others’ QI work:

This page is funded by our Medicare QIO Program Contract.