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Reducing Adverse Drug Events

Reducing Medication Errors Improving Individual Patient Care Overview

Adverse events secondary to medication therapy are the most common type of health care-associated adverse event. There is a growing awareness that many of these adverse events are due to medication errors, making Adverse Drug Events (ADEs) a major source of potentially preventable patient harm. ADEs disproportionately affect patients over the age of 65 across all settings including in hospital, ambulatory care and long-term care facilities.

Adverse Drug Events in the Community Outpatient providers who join in the QIO Program’s ADE initiative will be contributing to a national goal of reducing ADEs in 265,000 lives per year. In several communities in every state and territory, QIOs are bringing together clinical pharmacists, primary care clinics, and other providers that care for older patients with multiple chronic conditions who are at risk for the potentially negative consequences of polypharmacy. The initiative is modeled on the Health Resources and Services Administration’s successful Patient Safety and Clinical Pharmacy Services (PSPC) Collaborative. Participants can expect to benefit from participation in a statewide Learning and Action Network (LAN), access to evidence-based tools for assessing pharmacy processes and implementing safer practices, support for rapid-cycle improvement, and strategies for spreading success within their community.

VIMI is partnering with organizations currently participating in the Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) Breakthrough Collaborative(s). We will help lead two to three multidisciplinary community teams comprised of the following organizations:

  • Local clinical pharmacy representation
  • Clinicians from the multiple settings utilized by the targeted patient groups (e.g. hospitals, nursing homes, primary care clinics, specialty clinics, federally funded clinics, etc)
  • Clinic and/or hospital senior leadership
  • Patient and/or patient advocacy representation


We will identify and monitor patient groups for:

  • Persistently out-of-control health status based on established clinical health measures and standards such as HgA1c (glucose monitoring)
  • High medication risk due to multiple medications, multiple providers and/or inadequate medication use systems.


Specifically, beneficiaries shall meet one of the following criteria:

  • Are high-risk patients who have 5 or more chronic conditions and/or
  • Who take 9 or more medications on at least a weekly basis and/or
  • Are evaluated by 2 or more providers and/or
  • Take the anticoagulant Warfarin on a regular basis and/or
  • Take short-acting or long-acting antipsychotics of any class and/or
  • Take hypoglycemic medication for diabetes mellitus


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