Preventing Harm with the Use of Opioids, Anticoagulants and Insulin

The Hospital and Healthystem Association of Pennsylvania, in the Hospital Improvement Innovation Network (HIIN) Adverse Drug Events (ADE) project, provides tools and support, and facilitates collaboration to help facilities reduce harm associated with opioids, anticoagulants, and insulin.

Business Case:  According to data from the Pennsylvania Patient Safety Authority, opioids, anticoagulants, and insulin are among the most frequently reported high-alert medications to cause patient harm. During 2004, approximately one out of four reports involved high-alert medications with more than 80 percent of these involving these medications. Budnitz et al found that nine of the ten medications that most commonly caused patients 65 years of age and older to visit emergency departments were in three medication classes:

  • Oral anticoagulants or antiplatelet agents
  • Antidiabetic agents
  • Narrow therapeutic index agents

Together, these three medication classes caused nearly half of all emergency department visits for ADEs but were prescribed in only 9.4 percent of outpatient visits.

The Hospital and Healthsystem Association of Pennsylvania, in the Hospital Improvement Innovation Network (HIIN) ADE project, provides tools and supports, and facilitates collaboration to help facilities reduce harm associated with opioids, anticoagulants, and insulin.


  • Increase awareness of patient harm and unsafe processes associated with the use of opioids, anticoagulants, and insulin within organizations
  • Achieve and sustain a reduction in opioid, anticoagulant, and insulin ADEs

Past Accomplishments

  • During the last two years of the project, overall rates in episodes of hypoglycemia, use of reversal agents for insulin, and naloxone use in patients prescribed opioids fell by more than 25 percent
  • Reduced the number of reported serious events with opioids by 25 percent, and with insulin by 59 percent, compared to baseline data

Future Work

  • Webinars about a variety of topics associated with opioids, anticoagulants, and insulin
  • Newsletters that include up-to-date evidence-based practices, strategies, resources, toolkits, and checklists
  • Organization assessments to help facilities identify unsafe practices and deficiencies where they may focus their work
  • Networking by facilities during coaching calls where they share strategies, successes, challenges, and lessons learned
  • Small workgroups will be created to focus on specific processes associated with high-alert medications for rapid cycle improvement
  • Expert support through one-to-one calls to answer questions, assist with action plan development, onsite consultation (with low performers compared, or requesting hospitals)

HAP Contacts

For more information, contact Matthew Grissinger. For media inquiries, contact Rachel Moore, director, media relations.

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