Medication Use and Safety Measures List
The information contained on this page includes the measures which achieved expert consensus in the Medication Use and Safety domain.
How to Use This Measure List
This information provides the primary source for each measure specification, based on publicly available data. A brief numerator and denominator have been provided for all measures. For purposes of reporting and/or dashboard development, please refer to the details available via each data source. Full inclusion and exclusion criteria are detailed for each measure, as well as appropriate lists of ICD-10 codes and medications, where applicable. The measure specification language provided from each resource can be used to initiate conversations with analytics, quality, and/or informatics departments within your institution to pull the numerator and denominator data needed to monitor and benchmark performance on the selected Measure for Impact measures.
This measure list was prepared from existing quality measure sources to support pharmacy team members in the development and use of quality measure monitoring and dashboards. They have not been fully vetted or tested. Application will vary based on the system and they will need to be validated within your own institution. It may be easiest to test and implement measure reporting for one measure at a time. ASHP is not legally responsible for these measure definitions.
Released Date - October 2026
Measure Categories
Automated Dispensing Cabinet (ADC) Override Rate
Description:
Rate of ADC overrides (override occurs when a practitioner bypasses the pharmacist’s review of a medication order to obtain a medication from the ADC)
Calculation:
Numerator
Number of medications removed from a profiled ADC using override functionality
Denominator
Total number of medications removed from the ADC during the measurement period
Rate reported as
(Numerator / Denominator) × 100
- Source: ISMP
- More information is available at: https://home.ecri.org/blogs/ismp-resources/targeted-medication-safety-best-practices-for-hospitals
Barcode Medication Administration (BCMA) Utilization Rate
Description:
Percent compliance with both patient and medication scans at the bedside
Calculation:
Numerator
Number of bedside medication administrations where both the patient ID band and medication barcode were scanned
Denominator
Number of bedside medication administrations in units where BCMA is implemented
- Source: Leapfrog Hospital Survey
- More information is available at: https://ratings.leapfroggroup.org/measure/hospital/2026/safe-medication-administration
Naloxone Administration Rate
Description:
Rate of inpatient naloxone administration after receiving opioids
Calculation:
Numerator
Number of inpatient hospitalizations where naloxone was administered after documented opioid administration by hospital staff
Denominator
Number of inpatient hospitalizations with documented opioid administration
- Source: CMS
- More information is available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2026/cms0819v4
Programmable Infusion Pumps Utilization Rate
Description:
Percent of medication and hydration infusions programmed using the programmable infusion pump drug library.
Calculation:
Numerator
Number of medication and hydration infusions programmed using the smart infusion pump drug library
Denominator
Number of medication and hydration infusions administered via infusion pump
- Source: ISMP
- More information is available at: https://home.ecri.org/blogs/ismp-resources/targeted-medication-safety-best-practices-for-hospitals
Severe Hypoglycemia Episode Rate
Description:
Incidence of severe hypoglycemic episodes in patients who were administered at least one hypoglycemic medication during the encounter.
Calculation:
Numerator
Number of patient days with hypoglycemic event
Denominator
Number of patient days where glucose test is performed
- Source: CMS
- More information is available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2025/cms0816v4
Medication Reconciliation Rate at Admission
Description:
Percentage of patients receiving admission medication reconciliation by a pharmacy staff member.
Calculation:
Numerator
Number of patients with a home medication list documented and reconciled at admission by a pharmacy staff member
Denominator
Number of patients admitted, excluding newborns
- Source: AHRQ Publication No. 11(12)-0059
- More information is available at: https://www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-6a.html
Antimicrobial Days of Therapy (DOT)
Description:
Days of therapy (DOT) per antimicrobial: stratified by antibiotic per 1,000 days present
Calculation:
Numerator
Total days of therapy (DOT) for each antimicrobial agent
Denominator
Total days present
Rate reported as:
(Numerator / Denominator) × 1,000
- Source: NHSN (CDC) – Antimicrobial Use and Resistance
- More information is available at: https://cdc.gov/nhsn/psc/aur/index.html
Intensive Care Unit Venous Thromboembolism Prophylaxis Rate (eVTE-2)
Description:
Percentage of patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day after ICU admission (or transfer).
Calculation:
Numerator
Inpatient hospitalizations for patients who received VTE prophylaxis:
- the day of or the day after ICU admission (or transfer)
- the day of or the day after surgery end date (for surgeries that end the day of or the day after ICU admission or transfer)
Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:
- between the day of arrival and the day after ICU admission (for patients directly admitted as inpatients to the ICU)
- the day of or the day after surgery end date (for surgeries that end the day of or the day after ICU admission or transfer)
Denominator
Inpatient hospitalizations for patients directly admitted or transferred to ICU during the hospitalization
- Source: CMS
- More information is available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2027/cms0190v15
Venous Thromboembolism Prophylaxis Rate in Admitted Patients (eVTE-1)
Description:
Percentage of patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.
Calculation:
Numerator
Inpatient hospitalizations for patients who received VTE prophylaxis:
- between the day of arrival and the day after hospital admission
- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)
Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:
- between the day of arrival and the day after hospital admission
- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)
Denominator
Inpatient hospitalizations for patients discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics
- Source: CMS
- More information is available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2027/cms0108v15
VTE Prophylaxis Rate Ischemic or Hemorrhagic Stroke Patients (STK-1)
Description:
Proportion of ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission.
Calculation:
Numerator
Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission
Denominator
Inpatient hospitalizations for patients with ischemic or hemorrhagic stroke
- Source: Partnership for Quality Measurement (PQM)
- More information is available at: https://p4qm.org/measures/0434
Antithrombotic Therapy Rate by End of Hospital Day 2 In Ischemic Stroke Patients (STK-5)
Description:
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2.
Calculation:
Numerator
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival
Denominator
Patients discharged from non-elective inpatient care with a principal diagnosis of ischemic stroke
- Source: CMS
- More information is available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2027/cms0072v15
Ischemic Stroke Patients Discharged on Antithrombotic Therapy Rate (STK-2)
Description:
Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge.
Calculation:
Numerator
Inpatient hospitalizations for patients prescribed or continuing to take antithrombotic therapy at hospital discharge
Denominator
Patients discharged from non-elective inpatient care with a principal diagnosis of ischemic stroke
- Source: CMS
- More information is available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2027/cms0104v15
Anticoagulation Therapy for Atrial Fibrillation/Flutter Rate (STK-3)
Description:
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge.
Calculation:
Numerator
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation therapy at hospital discharge
Denominator
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter
- Source: CMS
- More information is available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2027/cms0071v16
Resources
Antimicrobial stewardship
- CDC Core Elements of Antibiotic Stewardship
- National Healthcare Safety Network (NHSN) – Antimicrobial Use and Resistance
Antithrombotic Stewardship
- Anticoagulation Forum – Antithrombotic Stewardship
- Agency for Healthcare Research and Quality (AHRQ) – Patient Safety Network (PSNet) - Advancing Anticoagulation Stewardship: A Playbook
Opioid Stewardship
- CDC Core Elements of Antibiotic Stewardship
- National Healthcare Safety Network (NHSN) – Antimicrobial Use and Resistance
Antithrombotic Stewardship
- Anticoagulation Forum – Antithrombotic Stewardship
- Agency for Healthcare Research and Quality (AHRQ) – Patient Safety Network (PSNet) - Advancing Anticoagulation Stewardship: A Playbook