The Problem
According to the Institute of Medicine (IOM) report, To Err Is Human, 6 to 10 percent of hospitalized patients every year in the US experience adverse drug events (ADEs).

The IOM report also references studies showing that ADEs result in an average additional cost of $4,700 per admission in a 700-bed teaching hospital, which equates to about $2.8 million annually for that hospital alone.

If generalized, this amounts to an additional $2 billion per year in costs for US hospitals as a result of ADEs.

Better Models of Care Exist
Barriers to reducing harm to patients include the complexity of the core processes designed into our medication systems, a punitive approach that inhibits reporting and open discussion of errors, and the tradition of focusing corrective action on individuals rather than on the underlying system failures. However, ADEs can be significantly reduced by implementing proven safety measures, such as standardizing and simplifying core medication processes in known high-risk areas, redesigning delivery systems using proven human factors principles, partnering with patients, and creating cultures in hospitals that minimize blame and maximize communication.

Sample Results

Iowa Health System (IHS) in Des Moines, Iowa, USA, reduced adverse drug events (ADEs) across its entire system of 10 hospitals by 75 percent in just one year.



IHS staff credit much of the system’s success in reducing ADEs to the commitment of senior leaders to creating a culture of safety. During Patient Safety Leadership WalkRounds™, senior leaders encourage front-line staff to identify opportunities for improvement and make suggestions. Regular unit Safety Briefings at IHS generated more than 600 good ideas for change. IHS collected these ideas in a database and implemented at least 35 percent of them.

OSF St. Joseph Medical Center in Bloomington, Illinois, USA, reduced ADEs per 1,000 doses by more than 50 percent in less than one year. 



The biggest change OSF made was improving its process for reconciling medications — for example, creating reconciliation tools (as simple as a wallet card and as complex as a medication system) to help patients provide complete information about the medications they are taking and to ensure they continue to receive appropriate medications while hospitalized and after discharge.
In addition to the new reconciliation process, OSF St. Joseph also implemented changes to create a culture of safety, such as Patient Safety Leadership WalkRounds™, Safety Briefings, the use of simulation for training, and the use of Failure Modes and Effects Analysis to improve the dispensing process. At the request of its physicians, OSF has readily shared its improvement ideas with competitor hospitals, in the belief that there are no boundaries or competition when it comes to patient safety.