Adverse Drug Events (ADE) Promoted from Aviator to Orbiting!
Over the last decade, through the application of culture, structure, and process interventions, together we have accelerated the pace of elimination of harm due to Adverse Drug Events (ADE). Since the improvement work began in 2011, the network has achieved a 73% reduction in ADE (Level F-I) (JAMA Pediatr. 2022). Given the sustained success with this measure, we are pleased to announce that ADE will be promoted from Aviator to Orbiting status on September 16, 2022.
With the achievement of this milestone, SPS hospitals will continue to submit ADE outcomes, but you can expect the following changes:
SPS will STOP collecting individual hospital data on ADE Roadmap elements and medication subtype data for Level E and F-I Adverse Drug Events.
Hospitals who wish to do so may extract their roadmap data until September 30, 2022. After this, hospitals may request this data from ochsps.data@cchmc.org.
The ADE Roadmap will be retained as reference resource, but as a static legacy document, it should be taken in the context of new and emerging evidence.
SPS will continue to monitor the rate of ADEs in the network using our SPS ADE operational definition and monitor for network level special cause variation. In addition, SPS will continue to provide materials such as the ADE Roadmap (now a legacy document), recorded webinars, and hospital level control charts. For hospitals who have chosen ADE as part of the 2022-2024 Hospital Selected Goal, individualized support will be provided. SPS expects that members will continue to develop, sustain, and evolve robust medication safety programs which incorporate safety culture fundamentals, implementation of the Institute for Safe Medication Practices (ISMP) best practices, and investments in technology to assist in prevention of serious medication errors. Looking forward, we anticipate that new medication safety opportunities will come to light as we launch the Ambulatory Safety portfolio.
Thank you for your dedication to eliminating serious harm across all children’s hospitals. If you have any additional questions or concerns, please don’t hesitate to reach out to us via email at ochsps@cchmc.org.