Adverse Drug Events

Medications are the most common intervention in health care and are also most commonly associated with adverse events in hospitalized patients. Older hospitalized patients are at higher risk of adverse drug events, in part due to their increased use of medications and co morbid conditions such as kidney and liver disease. An increase in the number of medications increases the likelihood of drug-drug and drug-disease interactions.

Not all medications in clinical use are of equal risk to patients. Serious adverse events appear to be caused by a relatively small number of medications. The Institute of Safe Medication Practice has identified a number of medications that they consider to be “high-alert medications.” These are defined by The Joint Commission as those medications which are more likely to be associated with harm than other medications—they cause harm more commonly, the harm they produce is likely to be more serious, and they “have the highest risk of causing injury when misused.”

Because of the complexity of attempting to identify and prevent all ADE’s, focusing surveillance and prevention of high alert medications may be a more prudent approach. The Institute for Healthcare Improvement’s 5 Million Lives campaign found that focusing on a few groups of high alert medications: anticoagulants, narcotics and sedatives, and insulin would have the greatest impact. These medications, due to their high volume of use coupled with their inherent risks, are responsible for the majority of harm due to all high-alert medications.

Adverse Drug Events Change Package

Partnership for Patients – Preventing Adverse Drug Events

For additional resources, please visit the HRET-HEN Website.