Pharmacy quality improvement experts at IPRO have created and field tested a unique audit tool aimed at reducing anticoagulant-related adverse drug events (ADEs) during care transitions. National estimates suggest that ADEs account for 700,000 emergency department visits and 120,000 hospitalizations annually, and The Department of Health and Human Services’ recently released National Action Plan for Adverse Drug Event Prevention identifies anticoagulant medications as a major contributor to preventable ADEs. IPRO’s Anticoagulation Discharge Communication tool (or “AC-DC” tool) evaluates the communication of 17 essential anticoagulation-related information elements to “downstream” healthcare providers upon patient discharge and transfer, highlighting potential system flaws and guiding improvements in communications. According to IPRO pharmacist and tool developer Anne Myrka: “the failure to effectively communicate critical elements such as when the next dose of an anticoagulant is due or when it should be discontinued can result in significant patient harm, and even death.” Because the tool is not specific to any single drug product or care setting, it can evaluate clinical communications relating to all currently available anticoagulants as well as newly marketed agents as they arrive, states Myrka. Preliminary field testing has been remarkably productive. The tool’s simplicity lends itself to rapid- cycle evaluations, speeding quality improvement efforts. The availability of the audit tool is welcomed by national leaders in anticoagulation safety. According to Dr. Jack Ansell, Professor of Medicine at Hofstra North Shore-LIJ School of Medicine: “the IPRO team’s effort constitutes an excellent example of a care transition management tool that shows substantial promise in reducing anticoagulant-related adverse drug events.” The AC-DC tool is presently available at ipro.org and preliminary results of field testing will be presented at a number of scientific conferences in coming months.