Driving Change: Reducing Adverse Drug Events

Posted on February 06, 2020

Driving Change is a monthly feature that highlights the work of Michigan hospitals and the Great Lakes Partners for Patients Hospital Improvement Innovation Network (GLPP HIIN) and provides resources to guide improvement.

Driving ChangeAccording to a study by the Office of Inspector General, adverse drug events (ADEs) – opioids, anticoagulation and hypoglycemia -  represent a third of all adverse events in hospitals among Medicare patients. Also, they affect 2 million hospital stays annually and prolong hospital stays by 1.7 to 4.6 days.


The opioid epidemic continues to be an area of concern throughout Michigan and the U.S. In 2017, Michigan saw 2,033 opioid-related deaths. In addition, overdose deaths increased by 17 times between 1999 and 2016. The GLPP HIIN continues its focus on opioid prescription reduction as well as effective opioid alternatives (ALTO) for pain management.

The MHA Keystone Center continues to promote work around appropriate medication disposal with the MHA Keystone Center Medication Disposal Toolkit, Pain Management Guide and 10 Things Every Patient in Pain Should Know Guide.

Additionally, the Midwest ALTO project, launched in 2018, is a multistate initiative that aims to reduce the administration of opioids in emergency departments by 15%. The first cohort of the Midwest ALTO project was a tremendous success. From Sept. 2018 to Jan. 2019, data showed an 11% decrease in opioid administration and a 13% increase in ALTO administration among 17 Michigan hospitals.


Anticoagulants are blood thinners used to reduce or prevent blood clots and predominantly used for the treatment of thromboembolic disorders, such as venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE).

While anticoagulants are highly effective, complications related to bleeding or hemorrhaging are a primary risk factor. Warfarin, a common anticoagulant, causes abnormal bleeding in an estimated 15 to 20% of patients per year.

Hospitals are encouraged to review the resources on the MHA Community site, including the ADE Anticoagulation Safety Starter Pack, for continuous improvement efforts.


Hypoglycemia is a condition that is caused by abnormally low blood glucose or sugar. It’s often related to diabetes and ranges from mild to severe. Severe hypoglycemia is a widespread concern among hospitalized patients and can lead to unconsciousness, cognitive impairment, seizures and death. Hypoglycemia is mostly avoidable and is an opportunity for improvement in care.

Hypoglycemia represents the third most common ADE. It’s connected to an increase in in-hospital mortality, longer hospital stays and higher medical costs. The MHA Keystone Center has resources available, such as webinars and a gap analysis to determine areas of opportunity within its ADE Glycemic Management Starter Pack on the MHA Community site. 

Members with questions may contact the MHA Keystone Center.


  • Driving Change: Reducing Adverse Drug Events

Tags: GLPP HIIN, opioids, anticoagulation, hypoglycemia, ADE

Posted in: Patient Safety and Quality

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