Adverse outpatient drug events—a problem and an opportunity.

William M Tierney

Commentary

Adverse outpatient drug events—a problem and an opportunity.

March 6, 2005

Tierney WM. N Engl J Med. 2003;348(16):1587-9.

View more articles from the same authors.

PubMed citation

Available at

Related Resources From the Same Author(s)

Physicians, information technology, and health care systems: a journey, not a destination.

March 6, 2005

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System—MEADERS.

December 1, 2010

Malpractice liability, patient safety, and the personification of medical injury: opportunities for academic medicine.

September 13, 2006

Narrative review: do state laws make it easier to say "I'm sorry"?

December 17, 2008

Screening electronic health record–related patient safety reports using machine learning.

March 1, 2017

Using a logic model to design and evaluate quality and patient safety improvement programs.

July 25, 2012

Another medical malpractice crisis?: Try something different.

October 14, 2020

Resolving malpractice claims after tort reform: experience in a self-insured Texas public academic health system.

December 7, 2016

Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system.

May 27, 2015

The role for leaders of health care organizations in patient safety.

September 19, 2007

Patient safety's missing link: using clinical expertise to recognize, respond to and reduce risks at a population level.

November 25, 2015

Health care consumers' inclination to engage in selected patient safety practices: a survey of adults in Pennsylvania.

December 12, 2007

Assessing and supporting late career practitioners: four key questions.

September 30, 2020

Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff.

July 2, 2014

Patient safety and the ageing physician: a qualitative study of key stakeholder attitudes and experiences.

October 10, 2018

Impact of a computerized physician order-entry system.

June 3, 2009

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.

April 28, 2010

The impact of the 80-hour resident workweek on surgical residents and attending surgeons.

July 12, 2006

Translating patient safety legislation into health care practice.

November 29, 2006

Can communication-and-resolution programs achieve their potential? Five key questions.

December 19, 2018

February 17, 2016

Structuring patient and family involvement in medical error event disclosure and analysis.

January 22, 2014

Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States.

December 17, 2008

Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.

June 8, 2005

Patients as partners in learning from unexpected events.

November 9, 2016

Implementing computerized provider order entry with an existing clinical information system.

August 23, 2006

Managing intraoperative stress: what do surgeons want from a crisis training program?

April 8, 2009

How policy makers can smooth the way for communication-and-resolution programs.

January 29, 2014

Quality and safety practices among academic obstetrics and gynecology departments.

August 30, 2023

Factors compromising safety in surgery: stressful events in the operating room.

February 10, 2010

Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017.

May 22, 2019

Listen carefully: the risk of error in spoken medication orders.

April 14, 2010

The effect of clinician feedback interventions on opioid prescribing.

April 27, 2022

The Patient Safety and Quality Improvement Act of 2005: developing an error reporting system to improve patient safety.

March 26, 2008

The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities.

January 31, 2007

Meaningful use of health information technology and declines in in-hospital adverse drug events.

March 8, 2017

Improving patient safety by practicing in a just culture.

July 12, 2017

Safe and appropriate use of insulin and other antihyperglycemic agents in hospital.

April 23, 2014

Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors.

July 27, 2005

Adverse events and patient outcomes among hospitalized children cared for by general pediatricians vs hospitalists.

January 9, 2019

Measure twice, cut once.

July 24, 2013

Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.

December 21, 2011

Changing our culture: adopting the military aviation safety system.

July 16, 2014

For whom the Bell Commission tolls: unintended effects of limiting residents' hours.

November 11, 2009

The physician's role in patient safety: what's in it for me?

February 13, 2008

Patient Safety and Quality Improvement Act of 2005.

May 10, 2006

Use of critical incident reports in medical education: a perspective.

November 16, 2005

The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration.

April 22, 2020

Health information technology and its effects on hospital costs, outcomes, and patient safety.

October 24, 2012

Evaluation of a healthcare safety climate measurement tool.

December 17, 2008

Medical students' experiences with medical errors: an analysis of medical student essays.

June 11, 2008

Every patient should be enabled to stop the line.

December 12, 2018

Opioid medication discontinuation and risk of adverse opioid-related health care events.

June 12, 2019

The "hidden curriculum" and residents' attitudes about medical error disclosure: comparison of surgical and nonsurgical residents.

October 9, 2013

Caught in the middle: a resident perspective on influences from the learning environment that perpetuate mistreatment.

March 23, 2016

A model of disruptive surgeon behavior in the perioperative environment.

October 15, 2014

An implementation strategy for a multicenter pediatric rapid response system in Ontario.

June 9, 2010

Patient safety and medical liability: current status and an agenda for the future.

September 8, 2010

The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients.

August 6, 2008

Fixing broken bones and broken homes: domestic violence as a patient safety issue.

March 6, 2005

Hospital finances and patient safety outcomes.

June 15, 2005

The coronavirus and the risks to the elderly in long-term care.

May 6, 2020

Organizational response to known medical errors: does peer review protection impede improvement?

May 30, 2018

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.

July 10, 2019

Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study.

August 15, 2012

Obstetric safety and quality.

August 26, 2015

The impact of resident duty hour and supervision changes: a review.

December 9, 2015

Making electronic health records both SAFER and SMARTER.

July 27, 2022

Improving patient safety in radiation oncology.

March 16, 2011

Making the business case for patient safety.

March 6, 2005

What do we know about financial returns on investments in patient safety? A literature review.

December 21, 2005

Case study: identifying potential problems at the human/technical interface in complex clinical systems.

November 30, 2005

Recalls and safety alerts affecting automated external defibrillators.

August 23, 2006

To err is human: quality and safety issues in spine care.

May 30, 2007

Another look at medical error.

March 6, 2005

Retrospective analysis of reported suicide deaths and attempts on veterans health administration campuses and inpatient units.

September 23, 2020

Electronic health record interoperability-why electronically discontinued medications are still dispensed.

September 22, 2021

A systems approach to identify factors influencing adverse drug events in nursing homes.

June 27, 2018

Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting.

May 15, 2013

Root causes of errors in a simulated prehospital pediatric emergency.

February 29, 2012

Association between day of delivery and obstetric outcomes: observational study.

December 9, 2015

Cost and workforce implications of subjecting all physicians to aviation industry work-hour restrictions.

May 6, 2009

The science and economics of improving clinical communication.

February 11, 2009

Are the Agency for Healthcare Research and Quality obstetric trauma indicators valid measures of hospital safety?

September 20, 2006

A trial of automated decision support alerts for contraindicated medications using computerized physician order entry.

June 29, 2005

Epidemiology, comparative methods of detection, and preventability of adverse drug events.

June 15, 2005

Error, blame, and the law in health care—an antipodean perspective.

March 6, 2005

What I wish I’d known: how experienced physician managers diagnose, treat and prevent disruptive behaviour.

September 21, 2022

Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial.

December 6, 2017

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

The effects of hospital-physician financial integration on adverse incident rate: an agency theory perspective.

October 21, 2020

Measuring safety of healthcare: an exercise in futility?

January 15, 2020

Strategies for flipping the script on opioid overprescribing.

November 23, 2016

Creating a culture of safety by using checklists.

March 13, 2013

Results of a national neurosurgery resident survey on duty hour regulations.

February 22, 2012

A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers.

September 7, 2011

Do patient safety events increase readmissions?

April 8, 2009

Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospital

August 25, 2021

The effectiveness of root cause analysis: what does the literature tell us?

June 25, 2008

Profiles in patient safety: a "perfect storm" in the emergency department.

June 20, 2007

Related Resources

Medication rounds: a tool to promote medication safety for children with medical complexity.

March 8, 2023

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

What is an ethically informed approach to managing patient safety risk during discharge planning?

January 20, 2020

New mother number 14.

March 20, 2019

Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach.

February 13, 2019

Infection prevention in the operating room anesthesia work area.

January 30, 2019

Learning from tragedy: the Julia Berg story.

December 12, 2018

A prescription for enhancing electronic prescribing safety.

December 12, 2018

Effective approaches to control non-actionable alarms and alarm fatigue.

September 12, 2018

A call for a systems-thinking approach to medication adherence: stop blaming the patient.

May 30, 2018

Diagnostic reasoning and cognitive biases of nurse practitioners.

April 25, 2018

Enhancing pediatric perioperative patient safety.

November 29, 2017

The power of regret.

October 25, 2017

Promoting civility in the OR: an ethical imperative.

March 8, 2017

Opioids for pain management in older adults: strategies for safe prescribing.

February 22, 2017

Patient and family empowerment as agents of ambulatory care safety and quality.

September 7, 2016

The problem with medication reconciliation.

August 31, 2016

What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.

August 24, 2016

The Feasibility of Determining the Effectiveness and Cost-effectiveness of Medication Organisation Devices Compared with Usual Care for Older People in a Community Setting: Systematic Review, Stakeholder Focus Groups and Feasibility RCT.

August 10, 2016

Incorporating indications into medication ordering—time to enter the age of reason.

August 10, 2016

ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors.

August 10, 2016

Guideline implementation: prevention of retained surgical items.

August 3, 2016

When less is better, but physicians are afraid not to intervene.

June 8, 2016

Back to basics: counting soft surgical goods.

April 20, 2016

Threats to safety during sedation outside of the operating room and the death of Michael Jackson.

April 20, 2016

Enhancing patient safety in pediatric primary care: implementing a patient safety curriculum.

November 4, 2015

Health literacy in primary care practice.

September 9, 2015

An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study.

November 26, 2014

Appropriate use of medical interpreters.

November 19, 2014

Out-of-hospital medication errors among young children in the United States, 2002–2012.

October 29, 2014

See More About The Topic

Ambulatory Care

Physicians

Nurses

Adverse outpatient drug events—a problem and an opportunity.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Adverse outpatient drug events—a problem and an opportunity.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site