Eliminating adverse drug events at Ascension Health.

Improvement in ADE rate did not occur at either hospital with any one particular intervention, or even after several conventional interventions had time to take effect. Instead, instituting many simultaneous system changes, proactively assessing risk, and expanding the scope of intervention were each essential to sustaining the described reductions in harm. The next step toward eliminating ADEs requires simultaneous communication across systems in a way that is manageable, approachable, and adaptable, and that supports the elements of change.