National Action Plan for Adverse Drug Event Prevention

Adverse drug events (ADEs) have been defined as an injury resulting from medical intervention related to a drug. ADEs can occur in any health care setting, including inpatient (e.g., acute care hospitals), outpatient, and long-term care settings (e.g., nursing homes). Given the U.S. population’s large and ever-increasing magnitude of medication exposure, the potential for harms from ADEs constitutes a critical patient safety and public health challenge. •Inpatient settings: ADEs comprise an estimated one-third of all hospital adverse events, affect approximately two million hospital stays annually, and prolong hospital length of stay by approximately 1.7 to 4.6 days. •Outpatient settings: ADEs account for over 3.5 million physician office visits, an estimated one million emergency department visits, and approximately 125,000 hospital admissions each year. The ADE Action Plan addresses a defined group of ADEs that are considered to be common, clinically significant, preventable, and measurable; resulting from high-priority drug classes; and occurring largely in high-risk populations. Three key drug classes identified as initial targets for the ADE Action Plan include: 1. Anticoagulants (primary ADE of concern: bleeding) 2. Diabetes agents (primary ADE of concern: hypoglycemia) 3. Opioids (primary ADE of concern: accidental overdoses, oversedation, respiratory depression) To align the efforts of federal health agencies to reduce patient harms from these specific ADEs nationally, the ADE Action Plan identifies a four-pronged approach: • Surveillance — Coordinate existing federal surveillance resources and data to assess the health burden and rates of ADEs. •Prevention — Share existing evidence-based prevention tools across federal agencies and with non-federal health care providers and patients. •Incentives and Oversight — Explore opportunities, including financial incentives and oversight authorities, to promote ADE prevention. •Research — Identify current knowledge gaps and future research needs (unanswered questions) for ADE prevention. One of the broader goals of the ADE Action Plan is to engage leaders at the federal, state, and local levels to implement evidence-based guidelines and engage in strategies that will help to prevent ADEs. The implementation of these strategies is expected to result in safer and higher quality health care services, reduced health care costs, informed and engaged consumers, and, ultimately, improved health outcomes. The ADE Action Plan also provides federal agencies and external stakeholders with a framework to identify strategies and select specific actions to take. The intended end‐users of the ADE Action Plan are policymakers, health care professionals, public and private sector organizations, and communities who can organize and take action toward preventing high‐priority ADEs.