title: The Adverse Drug Event Collaborative: a joint venture to measure medication-related patient harm.
abstract: OBJECTIVE
  To measure the extent of patient harm caused by medications (rate of Adverse Drug Events) in three DHBs, using a standardised trigger tool method.
  
  
  METHODS
  Counties Manukau, Capital and Coast and Canterbury DHBs decided to work collaboratively to implement the ADE Trigger Tool (TT). Definitions of ADE were agreed on and triggers refined. A random sample of closed charts (from March 2010 to February 2011) was obtained excluding patients who were admitted for <48 hours, children under the age of 18 and psychiatric admissions. In each DHB trained reviewers scanned these in a structured way to identify any of the 19 triggers. If triggers were identified, a more detailed, though time-limited review of the chart was done to determine whether an ADE had occurred. The severity of patient harm was categorised using the National Coordinating Council for Medication Error Reporting and Prevention Index. No attempt was made to determine preventability of harm and ADEs from acts of omission were excluded.
  
  
  RESULTS
  The ADE TT was applied to 1210 charts and 353 ADE were identified, with an average rate of 28.9/100 admissions and 38/1,000 bed days. 94.5% of the ADE identified were in the lower severity scales with temporary harm, however in 5 patients it was considered that the ADE contributed to their death, 9 required an intervention to sustain life and 4 suffered permanent harm. The most commonly implicated drugs were morphine and other opioids, anticoagulants, antibiotics, Non Steroidal Anti-Inflammatory Drugs (NSAIDs) and diuretics. Patients who suffered an ADE were more likely to be female, older with more complex medical illnesses, and have a longer length of stay.
  
  
  CONCLUSIONS
  The rate of medication-related harm identified by the ADE TT is considerably higher than that identified through traditional voluntary reporting mechanisms. The ADE TT provides a standardised measure of harm over time that can be used to determine trends and the effect of medication safety improvement programmes. This study not only shows the problem of medication-related patient harm, but it also shows the utility of informal collaboratives as a mechanism for change.
authors: Centre for Quality Improvement, Ko Awatea, Counties-Manukau DHB, Private Bag 93 311, Otahuhu, Auckland 1640, New Zealand. MZSeddon@middlemore.co.nz.
authors: Mary E
authors: ME
authors: Seddon
authors: Aaron
authors: A
authors: Jackson
authors: Chris
authors: C
authors: Cameron
authors: Mary L
authors: ML
authors: Young
authors: Linda
authors: L
authors: Escott
authors: Ashika
authors: A
authors: Maharaj
authors: Nigel
authors: N
authors: Miller
mesh_terms: D000328:Adult; D016907:Adverse Drug Reaction Reporting Systems / Q000145:classification / Q000458:organization & administration* / Q000706:statistics & numerical data; D000368:Aged; D015984:Causality; D002423:Cause of Death; D003299:Cooperative Behavior; D004185:Disability Evaluation; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D006801:Humans; D008020:Life Support Care / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009313:National Health Programs / Q000706:statistics & numerical data*; D009520:New Zealand; D010343:Patient Admission / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018570:Risk Assessment; D012494:Sampling Studies