Minnesota Hospital Association

Patient Safety

Adverse Drug Events

An adverse drug event (ADE) is an injury a patient incurs resulting from the use of a drug. In hospitals, examples of adverse drug events include medication errors such as accidental overdose or providing a drug to the wrong patient or by adverse drug reactions, such as an allergic reaction. According to the U.S. Department of Health and Human Services, patients in hospitals experience approximately 1.9 million adverse drug events annually, from events that cause little or no harm to those that result in death.   

Minnesota hospitals take the prevention of adverse health events seriously and are involved in many initiatives to reduce the number of adverse drug events in our hospitals. An adverse drug event advisory group has developed a road map based on evidence-based best practices focusing on anti-coagulants, hypoglycemic agents and opioids. The work of the advisory group has been highly anticipated nationally. The ADE road map will be a key component of the Partnership for Patients’ Medication Safety Affinity Group's (MSAG) support of the improved safety in the use of anticoagulants, insulin and oral hypoglycemic agents. MSAG, comprised of 24 Hospital Engagement Networks (HEN) and over 2,900 hospitals, is focused on collecting and disseminating results, best practices, and implementation strategies to improve medication safety. 

Download the MHA "Road Map to a Medication Safety Program" and following components of the road map:
Anticoagulation Agent Adverse Drug Event Gap Analysis;
Hypoglycemic Agent Adverse Drug Event Gap Analysis;
Opioid Adverse Drug Event Prevention Gap Analysis; and
VTE Prevention Strategies Gap Analysis.

Access the tool kit of best practices and resources on the bottom of this page to guide you in your efforts.

Adverse drug events are one of the 10 areas of focus being addressed through the Partnership for Patients Hospital Engagement Network. The Partnership estimates that 50 percent of all adverse drug events in hospitals each year are preventable.

Tool Kit for Hospital Staff

This tool kit provides best practices that hospitals can use to implement the Road Map to Medication Safety recommendations in their facilities. Hospitals may copy, translate, distribute and present the following items as long as you reference the Minnesota Hospital Association as the source of this material. If the tool is hospital-specific, please also cite the hospital as a source.

General documents

Glossary of acronyms and definitions

Queensland Health: Preventing adverse drug events tool kit

IHI: How-to guide to prevent harm from high alert medications

Emergency Hospitalizations for Adverse Drug Events in Older Americans (Budnitz)

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries

National Strategy for Quality Improvement in Health Care: Report to Congress

Rehospitalizations among Medicare Patients

Pharmacists on Rounding teams reduce preventable adverse drug events

VA Center for Med Safety - Adverse Drug Events, Adverse Drug Reactions and Medication Errors. FAQs

SAFE Document Resources and Tools

 S — Safety Teams and Organizational Structure

MAPS Just Culture Toolkit (Planning Phase, Early Implementation Phase, Making Good Progress Phase)

Patient and Family Advisory Councils: A Checklist for Getting Started

Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit

Patient Safety Councils

Dana Farber Patient and Family Advisory resources

AHRQ &  Aurora Health Care: "Guide for Developing a Community-Based Patient Safety Advisory Council"

MAPS Just Culture Toolkit: "Planning Phase" tools

A — Access to Information

MAPS Just Culture Toolkit: "Making Good Progress Phase" tools

Data Mining for ADE

F — Facility Expectations

A Consensus Statement of the Harvard Hospitals, "When Things Go Wrong – Responding to Adverse Events," Burlington, Massachusetts Coalition for the Prevention of Medical Errors, 2006

Premiere's sample hospital policies on disclosure

Full disclosure and apology article, Lucian L. Leape, M.D.

ECRI "Disclosure of Unanticipated Outcomes

Barnes Jewish Hospital: Example of "Stop the Line" policy

The Doctors Company Disclosure Resources

"The Basics of Healthcare Failure Mode and Effect Analysis" – Video conference course presented by VA National Center for Patient Safety

CNA HealthPro FMEA and RCA basics

Joint Commission FMEA tools

IHI FMEA Toolkit

Quality & Safety Education for Nurses: Lessons from the Lewis Blackman Story

Queensland Medication Reconciliation tool kit

Patient safety checklist

ASHP medication reconciliation tool kit

Improving Care Transitions - Optimizing Medication Reconciliation APA/ASHP 

E — Engagement of Patients and Families

AHRQ's Health Literacy Universal Precautions Toolkit

HRSA Culture, Language and Health Literacy

Stratis Health Cultural Competence resources

MN Health Literacy Partnership Teachback guide

Improving Patient Safety and Satisfaction via Patient Portals

Measuring the Impact of Patient Portals — What the Literature Tells Us

NPSF Fact Sheets and Guidelines for Patients and Consumers

MHA Model “Stop the line” policy

Joint Commission Speak Up materials

Hypoglycemic Gap Analysis Resources and Tools

Articles, documents and presentations

ASHP Safe Use of Insulin

Management of Diabetes and Hyperglycemia in Hospitals – Clement

Use of U-500 insulin – Cochran

Defining hypoglycemia - ADA

ADA presentation:  hypoglycemia harm reduction, C. Manchester

Hypoglycemia in diabetes article – Cryer

Use of U-500 Insulin in the Treatment of Severe Insulin Resistance, article – Cochran & Gorden

Concentrated U-50 0 insulin use, article – Segal

The Joint Commission Center for Transforming Healthcare Targets Safe Use of Insulin, article

Guidelines, algorithms and tools

NCCLS Point of Care Blood Glucose Monitoring guidelines

ICSI guidelines – Management of type II diabetes

Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline 

Pre-op guidelines

Data collection tool for hypoglycemia

Inpatient glycemic control guidelines

Regular Insulin U-500 Dosing Guidelines

U-500 cheat sheet

Diabetes algorithm

Sample order sets

Insulin SQ Prandial Carbohydrate dosing order set

Insulin SQ Non Carbohydrate dosing order set

Insulin pump order set

Adult central parenteral nutrition order set

Adult peripheral parenteral nutrition order set

Sample policies and protocols

U-500 insulin policy

Hypoglycemia treatment protocol

Insulin pump policy

TPN policy

Adult hypoglycemia policy

Adult hypoglycemia management protocol


Navy Medicine - staff education diabetes module presentation

Opioid Gap Analysis Resources and Tools

Articles, documents and presentations

"Managing Pain in the Surgical Patient," presentation from the Michigan Ambulatory Surgery Association

"Analgesic Tolerance to Opioids," article from the International Association for the Study of Pain

"Optimizing Optimal Pain Management," article - Ritchey, MD

"Treating Acute Pain in the Hospitalized Patient," Nurse Practitioner article

"A Survey of Acute Pain Service Structure and Function in U.S. Hospitals," article from Pain Research & Treatment

Shands at University of Florida - Drug Therapy Bulletin

Guidelines, algorithms and tools

Agency Medical Directors Group opioid dosing guidelines

San Diego Patient Safety Council PCA tool kit

Opioid-prescribing clinical tools and risk management strategies

American Pain Society range order guidelines

ICSI Assessment and Management of Chronic Pain guidelines

Joint Commission Sentinel Event alert: Safe Use of Opioids in Hospitals

Capnography Policy

Sample order sets

Pain PCA Adult Patient Controlled Analgesia

Opioid Tolerant Adult Pain order set

Opioid Naive Adult Pain order set


Pennsylvania HEN Opioid Knowledge self assessment tool

Results of the Opioid Knowledge Assessment from the PA Hospital Engagement Network Adverse Drug Event Collaboration

Nursing Care Plan

Anticoagulant Gap Analysis Resources and Tools

Articles, documents and presentations

Care Fusion - Improving Heparin Safety Proceedings

Guidelines, algorithms and tools

Joint Commission Sentinel Event alert: Preventing Errors Relating to Commonly Used Anticoagulants

Stroke measures: document

Warfarin INR Range and duration: document

CHEST guidelines

IHI Anticoagulation Tool Kit

ISMP Anticoagulant Self Assessment Tool


Education example: Anticoagulation for Prescribers Independent Study

Venous Thromboembolism (VTE) Resources and Tools

See MHA Gap Analysis and Tool Kit Resources