Improving Patient Safety through the National Action Plan for Adverse Drug Event Prevention


By Don Wright, MD, MPH, Deputy Assistant Secretary for Health, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services

Editor’s note: This post was first published on the Health Affairs Blog as part of a series of posts stemming from sessions at the June 2015 AcademyHealth Annual Research Meeting (ARM) in Minneapolis. Watch the Health Affairs Blog for additional posts on topics raised at the ARM

Every day, media reports about opioid overdose bring attention to growing concerns about the risks associated with this class of medication. Opioid overdose—as the result of unintentional dosage error, aberrant medication-related behavior, and other factors—is just one example of an adverse drug event (ADE) that is a significant cause of drug-related injury.

Although opioid overdose has been the subject of national headlines in recent months, ADEs from anticoagulants, such as blood thinners, and medicines to manage diabetes are also common, dangerous, and preventable, and deserve equal attention in national policy to protect the public’s health.

Consider that ADEs account for over 3.5 million physician office visits and an estimated 1 million emergency department visits annually. Further, an estimated one in three of all adverse events while patients are in the hospital are the result of ADEs, affecting about 2 million hospital stays each year. Now consider that approximately two in three of ADEs that occur in hospitals are related to opioids, anticoagulants, or diabetes agents. Imagine the dramatic improvements in patient safety that could be achieved if we could minimize the occurrence of ADEs from these three classes of medications.

The National Action Plan for Adverse Drug Event Prevention (ADE Action Plan) provides a framework to accomplish this goal. The plan calls for coordination among federal and non-federal stakeholders to reduce ADEs that are considered to be most common, resulting from opioids, anticoagulants, and diabetes agents; capable of causing clinically significant harm; preventable through efforts to share evidence-based prevention tools with health care providers and patients; measurable to allow for monitoring progress in prevention; and occurring largely in high-risk populations.

In June 2015, I led a policy roundtable at the Academy Health Annual Research Meeting to raise awareness of the critical need to address ADEs as a national patient safety and health care quality priority, and to discuss current and future steps for the ADE Action Plan. Featuring federal partners from the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services, the panel provided an introduction to the ADE Action Plan, discussed approaches for national surveillance of ADEs, outlined prevention strategies based on federal programs and policies, and discussed the role of public-private partnerships. The panel built on a growing momentum to address the significant public health challenge presented by ADEs.

The Development Of The ADE Action Plan

The ADE Action Plan was initiated in response to the Affordable Care Act’s health reform objective to improve health care quality and ensure patient safety, and a bipartisan letter from the U.S. Senate urging action to address growing concern about ADEs. The Office of Disease Prevention and Health Promotion (ODPHP) within the U.S. Department of Health and Human Services took on the development of the plan as part of our mission to provide leadership and coordination among federal agencies in the development of national health goals and objectives; we have performed this role for nearly 40 years through initiatives such as Healthy People 2020 and, more recently, the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination.

ODPHP convened a federal interagency steering committee and workgroups to provide oversight and expertise in the development and execution of the plan. The steering committee and workgroups identified three high-impact medication classes—opioids, anticoagulants, and diabetes agents—and four critical focus areas—surveillance, evidence-based prevention, incentives and oversights, and additional research needs—to include in the plan.

Moving Forward

Already, the ADE Action Plan has resulted in the ongoing development of national measures and targets for reducing ADEs. These measures and targets are due to be released for public comment in the coming year. Additionally, specific ADE prevention strategies for each of the medication classes and focus areas, such as setting individualized glycemic targets for patients with diabetes and increased use of electronic health records to improve care coordination among rural populations, are being addressed at a national level. The success of the ADE Action Plan will depend on ongoing coordination and collaboration across the federal government and among government agencies, national experts, and key public and private stakeholders.

As part of our focus on translating national policy into practice at ODPHP, we developed web-based, eLearning resources to reduce ADEs by increasing awareness and educating health care professionals on the principles outlined in the ADE Action Plan. The ADE Action Plan highlights health literacy as a key ADE prevention strategy and our trainings help ensure that health care professionals are able to convey complex health information to their patients in language that is easy to understand. We encourage health care professionals to earn free continuing education credits by taking the Pathways to Safer Opioid Use and Preventing Adverse Drug Events: Individualizing Glycemic Targets Using Health Literacy Strategies trainings to help in our national effort to prevent ADEs.