title: An internal quality improvement collaborative significantly reduces hospital-wide medication error related adverse drug events.
abstract: OBJECTIVE
  To reduce the rate of harmful adverse drug events (ADEs) of severity level D-I from a baseline peak of 0.24 ADE/1000 doses to 0.08 ADE/1000 doses.
  
  
  METHODS
  A hospital-wide, quasi-experimental time series quality improvement (QI) initiative to reduce ADEs was implemented. High-reliability concepts, microsystem-based multidisciplinary teams, and QI science methods were used. ADEs were detected through a combination of voluntary reporting, trigger tool analysis, reversal agent review, and pharmacy interventions. A multidisciplinary ADE Quality Collaborative focused on medication use processes, not on specific classes of medications. Effective interventions included huddles and an ADE prevention bundle.
  
  
  RESULTS
  The rate of harmful ADEs initially increased by >65% because of increased error reporting, temporally associated with the implementation of a program focused on high reliability and an improved safety culture. The quarterly rate was 0.17 ADE/1000 dispensed doses in Q1 2010. By the end of Q2 2013, the rate had decreased by 76.5%, to 0.04 ADE/1000 dispensed doses (P < .001).
  
  
  CONCLUSIONS
  Using an internal collaborative model and QI methodologies focused on medication use processes, harmful ADEs were reduced hospital-wide by 76.5%. The concurrent implementation of a high-reliability, safety-focused program was important as well.
authors.affiliation: Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, Division of Neonatology, The Ohio State University, Columbus, OH. Electronic address: rick.mcclead@nationwidechildrens.org.
authors.forename: Richard E
authors.initials: RE
authors.lastname: McClead
authors.affiliation: Nationwide Children's Hospital, Columbus, OH.
authors.forename: Charline
authors.initials: C
authors.lastname: Catt
authors.affiliation: Nationwide Children's Hospital, Columbus, OH.
authors.forename: J Terrance
authors.initials: JT
authors.lastname: Davis
authors.affiliation: Nationwide Children's Hospital, Columbus, OH.
authors.forename: Shelly
authors.initials: S
authors.lastname: Morvay
authors.affiliation: Nationwide Children's Hospital, Columbus, OH.
authors.forename: Jenna
authors.initials: J
authors.lastname: Merandi
authors.affiliation: Nationwide Children's Hospital, Columbus, OH.
authors.forename: Dorcas
authors.initials: D
authors.lastname: Lewe
authors.affiliation: Nationwide Children's Hospital, Columbus, OH.
authors.forename: Barbara
authors.initials: B
authors.lastname: Stewart
authors.affiliation: Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, Division of Critical Care Medicine, The Ohio State University, Columbus, OH.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Brilli
mesh_terms: D016303:Clinical Pharmacy Information Systems; D017723:Drug Utilization Review; D006760:Hospitalization; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D008510:Medication Systems, Hospital / Q000458:organization & administration; D015279:Organizational Culture; D064406:Patient Harm / Q000517:prevention & control* / Q000706:statistics & numerical data; D058996:Quality Improvement; D017751:Safety Management