Published in 2014, the U.S. Department of Health and Human Services (HHS)’ National Action Plan for Adverse Drug Event (ADE) Prevention serves as a road map for coordinating federal efforts to reduce preventable ADEs and for raising awareness of the importance of medication safety. The plan identifies efforts to measure and prevent ADEs, and outlines future opportunities to prevent ADEs among three primary drug classes: anticoagulants, diabetes agents and opioids.
The CMS QIO Program aligns with the National Action Plan through its coordination of care focus and its associated ADE reduction activities. One particular organization that is excelling in this area is New York-based IPRO, which leads the Atlantic Quality Innovation Network (AQIN) under the CMS QIO Program.
In 2014, IPRO debuted a pair of free tools for hospitals that are designed to improve health care quality and prevent ADEs. The first tool – known as “MAP” (Management of Anticoagulation in the Peri-Procedural Period) is a clinical tool used by providers in real-time to determine how, whether and when to stop the use of warfarin and other anticoagulants before surgery and other invasive procedures. IPRO designed the evidence-based tool under the auspices of the Peri-Procedural Task Force of the New York State Anticoagulation Coalition.
IPRO also piloted the AC-DC (Anti-Coagulation Discharge Communication) audit tool in 2014 and has since made it available to providers in six care transitions communities in New York. Designed for hospitals, nursing homes, rehabilitation centers and home health agencies, this tool is a simple one-page form that medical provider staff can quickly fill out to evaluate the effectiveness of the facility’s communications to other providers about discharged or transferred patients’ anti-coagulation drug usage. IPRO’s pilot project showed that significant improvements can be made in anticoagulation-related communications across care settings, and a number of facilities have reported that they successfully prevented drug errors by using the tool.
Both ADE prevention tools are available for free download on the AQIN website.