The National Coordinating Council for
Medication Error Reporting and Prevention (NCCMERP)
has created an Adverse Drug Event (ADE)
algorithm. An ADE is injury resulting from medical intervention related to a drug. The Council has
frequently been asked to help healthcare professionals distinguish among Adverse
Drug Events (ADEs), Adverse Drug Reactions (ADRs)
and Medication Errors. The Council notes
several definitions for these terms in the literature, research reports, and by various organizations.
The tool identifies decision points for determining whether an ADE is preventable and helps
distinguish terms such as adverse drug reactions, adverse drug events and medication errors. The
Council proposes new terminology to clarify the terms and the relationships among them and
encourages consistent adoption across the medication safety community.
Adverse drug events (ADEs) are among the most common causes of health-care related harm, affecting
approximately two million hospital stays and accounting for an estimated 3.5 million physician
office visits and one million emergency department (ED) visits per year according to the National
Action Plan for Adverse Drug Event Prevention. Additionally, at least 20% of all harm to
hospitalized patients is associated with medications.
The algorithm, titled, “Contemporary View of Medication-related Harm. A New Paradigm”, was
generally designed to apply to any medication-related event and to help practitioners and
healthcare facilities decide if harm could have been prevented. This tool may aid in developing
policies and procedures to mitigate harm.
The aim of this algorithm and its associated case scenarios is to assist practitioners and
researchers in developing methods to identify ADEs and clarify definitions to improve the ability
of hospitals to minimize exposure to medication-related harm. This tool should be useful for
researchers and those who work on medication safety