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Eliminating Adverse Drug Events at Ascension Health

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Background: 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.

Implementation: Our Lady of Lourdes Memorial Hospital (Binghamton, New York) and Saint Thomas Hospital (Nashville, Tennessee) used the ADE Trigger Tool to make significant changes to prevent, detect, and mitigate harm from ADEs in the medication use process.

Results: At Our Lady of Lourdes, ADEs per 100 patient days have not statistically changed from the baseline mean of 1.39 (November 2003–October 2004) to a mean of 1.11 (October 2006–June 2007). At Saint Thomas, ADEs per 100 patient days decreased from a baseline mean of 3.04 (November 2003–October 2004) to a mean of 1.21 (October 2006–June 2007), representing a 60% reduction. ADE Trigger Tool results have not shown a consistent reduction in ADEs across Ascension Health.

Discussion: The decreased harm rate from ADEs reflected not the types of standardization and process changes typically thought of as being effective means of reducing ADEs but rather the hospital becoming more proactive at addressing potential ADEs, leveraging education through the use of new technology and developing a new mindset on how these events are viewed in the hospital.

Document Type: Research Article

Publication date: September 1, 2007

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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