As the principal impact measurement arm of the Department of Health and Human Services (HHS) Partnership for Patients initiative, the Agency for Healthcare Research and Quality (AHRQ) established that there were 2.1 million fewer incidents of patient harm in 2011, 2012, 2013, and 2014 in comparison to the 2010 base year, including a dramatic 40% reduction in Adverse Drug Events (ADE), the largest single category of hospital harm. These impressive national results were driven by an aligned, collaborative, synergistic set of federal and private sector initiatives. The Federal interagency partnership included active participation from AHRQ, the Centers for Medicare & Medicaid Services (CMS), the Veterans Administration (VA), the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the Administration for Community Living (ACL), the Indian Health Service (IHS), the Office of the National Coordinator (ONC) for Health Information Technology, the Office of the Assistant Secretary for Health (OASH), with frequent participation and representation from the Food and Drug Administration (FDA), the Department of Defense (DoD), patients, national association partners, frontline caregivers, hospital partners, universities, and others. A number of key initiatives were at the “center of the action” that drove national progress, including:
- AHRQ’s National Scorecard for tracking national progress on ADEs and 20 other forms of patient harm
- CMS Quality Improvement Organization (QIO) program work in both the 10th and 11th Scopes of Work
- HHS National Action Plan for ADE Prevention
- HHS Partnership for Patients initiative and the CMS-supported Hospital Engagement Networks (HENs)
- HRSA’s Patient Safety and Clinical Pharmacy Services Collaborative
Each of these key national initiatives worked together with frontline pharmacists, physicians, nurses, and other caregivers to generate the substantial reductions in adverse drug events that have been documented now by the AHRQ National Scorecard for the period 2011 through 2014.