Author: IPRO

The National Action Plan for Adverse Drug Event Prevention (ADE Action Plan) was established to address two key objectives: (1) identify common, preventable, and measurable adverse drug events (ADEs) that may result in significant patient harm; and (2) align the efforts of Federal health agencies to reduce patient harms from these specific ADEs nationally.

On the basis of national ADE data from inpatient and outpatient settings, three types of ADEs were considered to be common, clinically significant, preventable, and measurable, and were therefore selected as the high-priority targets of the ADE Action Plan.
The three initial targets of the ADE Action Plan are:
1. Anticoagulants (primary ADE of concern: bleeding)
2. Diabetes agents (primary ADE of concern: hypoglycemia)
3. Opioids (primary ADE of concern: accidental overdoses/over sedation /respiratory depression)

The ADE Action Plan suggests a four-pronged approach to reduce patient harms from these three ADEs: Surveillance, Prevention, Incentives and Oversight, and Research.

The Monthly Falls Tracking Form was developed to assist facilities track their falls on a monthly basis. It maintains an active list of all falls in real time to assist with both investigation and provide an important piece in the development of a targeted fall prevention program. (See instructions below on how to download the tracking form.)

Complete this form to receive a link to download a zipped folder of the Falls Tracking Resources to include the Excel tracking form as well as a PDF instructional guide that explains the use of the tool.

For questions on the Monthly Falls Tracking Form and Guide, please contact Dave Johnson (djohnson@ipro.org) or IPRONursingHomeTeam@IPRO.org.

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“The Decision Guide tools and resources have really helped us think differently on how we can prepare our Residents and Families for changes in condition and to let them know, WE take care of them in our Nursing Facility.” NC SNF

This tool was developed by CMS for use by nursing home surveyors and is a valuable resource for organizations that are focusing on preventing ADEs.

It was designed to help surveyors identify:

1. The extent to which facilities have identified resident-specific risk factors for adverse drug events

2. The extent to which facilities developed and implemented systems and processes to minimize risks associated with medications that are known to be high-risk and problem-prone

3. When a preventable adverse event has occurred, evaluate if the nursing home identified the issue and responded appropriately to mitigate harm to the individual and prevent recurrence.

This website contains the MDS 3.0 RAI Manual v1.17.1 and MDS forms, effective October 1, 2019. This version of the MDS 3.0 RAI Manual incorporates clarifications to existing coding and transmission policy; it also addresses clarifications and scenarios concerning complex areas. Since the preliminary release of the manual on May 20, 2019, changes have been made to clarify which assessments swing bed providers must complete; the definition of the “interruption window” for interrupted Part A-covered stays; the coding of item I0200B; and changes related to group therapy policies, as well as other corrections. Please see the document titled “MDS 3.0 RAI Manual v1.17.1 Replacement Manual Pages and Change Tables_October 2019” posted in the Related Links section at the bottom of this page.

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in everyday practice in long-term care centers.

INTERACT is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital.

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