Monitoring, Reporting, and

Communicating
ADR-Monitoring and Reporting Programs
necessary to detect, evaluate, and develop mechanisms to
prevent ADRs and their associated morbidity, mortality, and
increased costs.

Alerting Orders- prescriptions which alert pharmacists that

an ADR may have occurred and an investigation should be
conducted.
Types:
Tracer drugs used to treat ADRs
Abrupt discontinuation or decrease in dosage
Stat orders for laboratory assessments
Who are Most At Risk for ADRs?
Those with most trouble adjusting to the
negative consequences
Pediatric patients less predictable drug responses
Elderly patients - taking multiple medications and
greater sensitivity to medications
Oncology patients exposed to highly toxic
therapeutic regimens/immunocompromised
How Do We Report an ADR?
1. Report the adverse reaction immediately after it
occurs.
2. Prescribers, Nurses and Pharmacists should be
notified
3. Think about any other factors which may
contribute in causing the Event.
4. Serious or unexpected ADR should be reported
to the FDA or the drugs manufacturer
Why Arent ADRs Reported?
Lack of knowledge about the reporting systems
or perceived difficulty
Uncertainty about whether or not a drug is the
cause of an adverse event
Lack of time or high workload
Lack of understanding about why it is important
to report
Complacency
Medication Reconciliation
Attempts to correct problems such as
Omissions in therapy
Medication duplication
Errors in dosing
Potential drug interactions
Conducted each time a patient transitions across
departments or location.
Medication Reconciliation Process

1.Verification
2.Clarification
3.Reconciliation
4.Transmission
National Quality Organizations
-Promote Health Care Quality and Patient Safety
The Institute of Medicine

Institute for Healthcare Improvement

Improve health care throughout the world

National Quality Organizations
National Quality Forum

The Leapfrog Group

National Quality Organizations
Joint Commission

Centers for Medicare and Medicaid Service

National Quality Organizations
Agency for Healthcare
Research and Quality

National Committee for Quality Assurance

National Quality Organizations
American Society of
Health-System
Pharmacists

Pharmacy Quality Alliance