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
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.
NCPIE encourages healthcare professionals and community groups to foster patient–professional communication about medicines. However, NCPIE does not supervise or endorse the activities of any group or professional. Discussion and action concerning medicines are solely the responsibility of the patient and their healthcare professionals, and not NCPIE.
Please consult a licensed health care professional with questions or concerns about your medication and/or condition.