# Developing and implementing a new health information technology innovation to improve patient safety in the Canadian context

## TL;DR

This paper introduces ActionADE, a new health IT tool designed to prevent recurring adverse drug events by alerting pharmacists to harmful medication histories.

## Contribution

The novel contribution is the development and implementation of ActionADE, an interoperable HIT system tailored to the Canadian healthcare context.

## Key findings

- ActionADE was successfully integrated with the provincial medication dispensing database to alert pharmacists about harmful drug re-exposures.
- Co-design and use of clinical data standards were critical to the system's functionality and adoption.
- Health system leaders must plan for scaling successful HIT innovations to maximize public benefit.

## Abstract

Adverse Drug Events (ADEs) are unintended and harmful events related to medication use. Many ADEs recur because patients are unintentionally re-exposed to medications that previously caused harm. To help address this, we designed ActionADE, an interoperable Health Information Technology (HIT) that allows clinicians to communicate ADEs across health sectors. We completed ethnographic workplace observations and a systematic review to inform design. After piloting, we integrated ActionADE with the provincial medication dispensing database to alert pharmacists when patients seek to fill a prescription for the same or a same-class drug as one that previously caused harm. Co-design, application of clinically meaningful field labels and data standards, and integration with other health information systems were critical to ActionADE’s functionality and use. However, health system decision-makers need to proactively plan for how to spread and scale pilot project in the HIT ecosystem to ensure public benefit from successful innovation.