Medication Safety

Better care through better medication management

Reducing Harm from Medications

National estimates suggest that Adverse Drug Events (ADEs) contribute an additional $3.5 billion to United States healthcare costs. Given the United States population’s large and ever-increasing magnitude of medication exposure, the potential for harm from ADEs is a critical patient safety and public health challenge. ADEs can include, but are not limited to, medication errors, adverse drug reactions, allergic reactions and overdoses.

The Great Plains QIN is partnering with providers, pharmacists and stakeholders in the region to reduce and monitor ADE rates. We are targeting Medicare Fee-for-Service (FFS) consumers taking three or more medications, including at least one of these high-risk medications: anticoagulants, diabetic agents and/or opioids, for improvement. Tools, education and trainings will be offered. Specific goals include:

  • Reducing ADEs by 35 percent per 1,000 screened Medicare consumers by 2019
  • Monitoring ADE rates by Medicare consumers on anticoagulants, diabetic agents and/or opioids by care setting, state, region and readmission rate
For more information on how medication safety is a key element to improved care coordination, visit the Care Coordination Initiative page of this site.


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Initiative Documents
Medication Prescribing for the ElderlyMedication SafetyPrescribing Guidelines for the ElderlyQIN-QIO
Current ADA guidelinesDiabetic AgentsAmerican Diabetes Association Standards of Medical Care in Diabetes – 2016American Diabetes Association
CDC Guideline for Prescribing Opioids for Chronic PainResourceGuideline for Prescribing Opioids for Chronic PainCDC
AACE Comprehensive Diabetes Management Algorithm – 2016Diabetic AgentsAACE Comprehensive Diabetes Management Algorithm – 2016American Association of Clinical Endocrinologists’
Joint Commission overview of the issue of anticoagulation safety within hospitalsAnticoagulants-HospitalsJoint Commission Sentinel Event: Preventing Errors Related to Commonly Used AnticoagulantsJoint Commisiion
Joint Commission overview of the issue of opioid safety within hospitalsOpioids-HospitalJoint Commission Sentinel Event: Safe Use of Opioids in HospitalsJoint Commission
Medication Safety Toolkit - A Licensed Nurse’s Guide to Medication Safety in North Dakota Assisted Living/Basic Care FacilitiesToolA Licensed Nurse’s Guide to Medication Safety in North Dakota Assisted Living/Basic Care Facilities Quality Health Associates of North Dakota
This paper estimates the time spent to address medication reconciliation issues in care transitions between hospitals and nursing homes, using care transition examples, and makes recommendations for action by hospitals, nursing homes and pharmacists to improve the medication reconciliation process.Medication ReconciliationStratis Health White Paper 2014: Understanding and Improving Medication Reconciliation Between Hospitals and Nursing HomesStratis Health
Preventing Adverse Drug Events through Improved Medication Safety and Care CoordinationMedication SafetyAdverse Drug Events and Medication Safety Environmental Scan OverviewGPQIN
Campaign for Meds Management Evaluation ToolToolAdverse Drug Event Causality EvaluationQIO Program
Campaign for Meds Management Provider Causality FlowchartToolProvider Causality FlowchartQIO Program
Initiative Links
AnticoagulantsAnticoagulation ADEs – An Old Problem: A New Focus (recorded webinar)
AnticoagulantsMAQI Anticoagulation Toolkit
Medication SafetyBeers Criteria for Potentially Inappropriate Medication Use in Older Adults
Adverse Drug EventsIHI Trigger Tools for Measuring Adverse Drug Events
OpioidsPathways to Safer Opioid Use
OpioidsOpioid ADEs – An Old Problem: A New Focus (recorded webinar)
OpioidsNational Institute on Drug Abuse (NIDA) Physician Tools
OpioidsHHS Action to Address Opioid-Drug Related Overdoses & Deaths
Medication SafetyVA/DoD Clinical Practice Guidelines
Medication SafetyISMP High-Alert Medications
Medication SafetyBlood Pressure Control
OpioidsSearch and Rescue
Medication ReconciliationSHM MARQUIS Medication Reconciliation Toolkit
Health LiteracyAHRQ Pharamcy Health Literacy Center
Diabetic AgentsVA/DoD Clinical Guidelines Diabetes
Diabetic AgentseLearning Course: Preventing ADE-Individualizing Glycemic Targets
OpioidsOpioid Prescribing: Safe Practice, Changing Lives (free CE available-registration required)
OpioidsMedicare Part D Opioid Drug Mapping Tool
Diabetic AgentsIHS Division of Diabetes Treatment and Prevention
Medication ReconciliationMedication Safety Reconciliation Toolkit in North Carolina
Medication ReconciliationHow-to Guide: Prevent Adverse Drug Events by Implementing Medication Reconciliation
Medication SafetyISMP (Institute for Safe Medication Practices)
Medication ReconciliationAHRQ Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
OpioidsPainEDU Pain Management Resources
Medication Safety-Community PharmacyAHRQ Community Pharmacy Survey on Patient Safety Culture
Adverse Drug Events-Hospitalospital Improvement Innovation Network Adverse Drug Events
OpioidsVA/DoD Clinical Guidelines – Pain
Adverse Drug EventsInstitute for Safe Medication Practices HAMMERS
Adverse Drug EventsInstitute for Safe Medication Practices Risk Assessment
AnticoagulantsAnticoagulation Forum
OpioidsAPhA Opioid Use, Abuse and Misuse Resource Center
As You Age Educational GuidebookAs You Age...A Guide to Aging, Medicines and Alcohol
Educational Resource: Ensuring Safe Use of MedicineFDA Medication Safety
OpioidsCDC Guideline for Prescribing Opioids
Adverse Drug EventsPartnership for Patients
Adverse Drug EventsNational Action Plan for Adverse Drug Event Prevention
Medication SafetyMedication Use Safety Training for Seniors (MUST)
Consumer ResourcesGreat Plains QIN Consumer Medication Safety Resources
Adverse Drug EventsStandard of Nursing Practice Protocol: Reducing Adverse Drug Events
Medication SafetyGeriatric Medication Management Toolkit
Mar 28 @ 12:00 pm – 1:00 pm
Join the Great Plains Quality Innovation Network Care Coordination Team for the fourth in this series of action-oriented learning events. This WebEx session will help your organization build capacity for better, safer care and healthier[...]
Jan 24 @ 12:00 pm – 1:00 pm
The Great Plains QIN Care Coordination Team held this third in a series of action-oriented learning events to help organizations build capacity for better, safer care and healthier people and communities. Start WebEx Playback Medication Safety Presentation Handout Medication safety[...]
Dec 20 @ 12:00 pm – 1:00 pm
  This month, the Great Plains QIN is providing the opportunity to participate in a Coaching Call with peers and experts in the field regarding any one of the following three topics: reducing rehospitalizations, medication[...]
Oct 25 @ 12:00 pm – 1:00 pm
Rehospitalizations – Medication Safety – Chronic Disease Management Start WebEx Playback Presentation Handout Recording Transcript Join the Great Plains QIN Care Coordination Team for a series of action-oriented learning events over the next several months[...]
Jul 23 @ 2:00 pm – 3:00 pm
    Start WebEx Playback Presentation Handout WebEx Overview This event will provide an introduction to the care coordination and medication safety Learning and Action Network (LAN). Included will be the patient/family perspective, overview of[...]
Medication Safety Contacts
Paula SitzmanRN, BSNQuality Improvement AdvisorNebraskaPaula.Sitzman@area-a.hcqis.org
Jayme Steig (co-lead)PharmD, RPHPharmaceutical Care SpecialistNorth DakotaJayme.Steig@area-a.hcqis.org
Sally May (co-lead)RN, BSN, CH-GCNSenior Quality Improvement SpecialistNorth DakotaSally.May@area-a.hcqis.org
Linda PenistenRN, OTR/LProgram ManagerSouth DakotaLinda.Penisten@area-a.hcqis.org
Vanessa LamoreauxProject ManagerKansasVLamoreaux@kfmc.org

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Learning and Action Network

We invite you to join the Great Plains Learning and Action Network (LAN). All LAN partners will be invited to attend educational sessions on a variety of topics, have opportunities to learn from peers throughout the state and region and have access to an abundance of resources and tools. The LAN is a great opportunity to get connected and demonstrate your commitment to quality improvement.

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