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

Julie C. Lauffenburger; Niteesh K. Choudhry

Commentary

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

May 30, 2018

Lauffenburger JC, Choudhry NK. JAMA Intern Med. 2018;178(7):950-951.

View more articles from the same authors.

Systems thinking has been applied to address various underlying conditions that contribute to medical errors. This commentary discusses factors that affect patient medication nonadherence and suggests that a systems thinking approach can enable reliable patient use of prescription medications.

PubMed citation

Available at

Related study

Related Resources From the Same Author(s)

Prescribing decision making by medical residents on night shifts: a qualitative study.

November 9, 2022

Patient factors associated with new prescribing of potentially inappropriate medications in multimorbid US older adults using multiple medications.

May 12, 2021

Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge.

November 2, 2016

Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis.

January 31, 2006

Variability in pharmacy interpretations of physician prescriptions.

March 4, 2009

The variability and quality of medication container labels.

September 19, 2007

Standardized patient identification and specimen labeling: a retrospective analysis on improving patient safety.

October 3, 2012

Study of a multisite prospective adverse event surveillance system.

July 31, 2019

Deficiencies in provider-reported interpreter use in a clinical trial comparing telephonic and video interpretation in a pediatric emergency department.

October 14, 2020

It’s time to consider national culture when designing team training initiatives in healthcare.

January 27, 2021

Communicating in the "gray zone": perceptions about emergency physician-hospitalist handoffs and patient safety.

October 17, 2007

Nurses' perceptions of safety culture in long-term care settings.

July 8, 2009

Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety.

January 13, 2010

Outpatient adverse drug events identified by screening electronic health records.

June 9, 2010

Does user-centred design affect the efficiency, usability and safety of CPOE order sets?

May 4, 2011

Usability evaluation of order sets in a computerized provider order entry system.

August 24, 2011

A randomized trial of electronic clinical reminders to improve medication laboratory monitoring.

July 23, 2008

The reliability of AHRQ Common Format Harm Scales in rating patient safety events.

October 23, 2013

Housestaff and medical student attitudes toward medical errors and adverse events.

August 1, 2007

Drug-induced hypoglycaemia--new insight into an old problem.

October 25, 2006

Inter-rater reliability of a classification system for hospital adverse drug event reports.

September 12, 2007

Developing perioperative Covid-19 testing protocols to restore surgical services.

July 22, 2020

Improving acceptance of computerized prescribing alerts in ambulatory care.

November 9, 2005

Medical malpractice lawsuits involving surgical residents.

September 20, 2017

Adherence to black box warnings for prescription medications in outpatients.

February 22, 2006

Documentation of drug allergy on drug chart in patients presenting for surgery.

July 9, 2008

Preventing complications of central venous catheterization.

March 6, 2005

The evolution of patient safety procedures in an oral surgery department

December 11, 2019

Using human error theory to explore the supply of non-prescription medicines from community pharmacies.

August 23, 2006

Overestimation of clinical diagnostic performance caused by low necropsy rates.

December 14, 2005

Surgical specimen identification errors: a new measure of quality in surgical care.

April 11, 2007

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

March 1, 2023

Human factors in anaesthesia: a narrative review.

February 15, 2023

Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey.

October 14, 2015

Improving maternal safety at scale with the mentor model of collaborative improvement.

May 23, 2018

Developing a primary care patient measure of safety (PC PMOS): a modified Delphi process and face validity testing.

July 22, 2015

An experimental study in nurse-physician relationships.

August 2, 2006

The effect of provider characteristics on the responses to medication-related decision support alerts.

July 15, 2015

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety.

December 19, 2007

Nurses' workarounds in acute healthcare settings: a scoping review.

June 19, 2013

Reevaluating the safety profile of pediatrics: a comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment.

June 4, 2008

ED handoffs: observed practices and communication errors.

July 20, 2011

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

August 19, 2020

A cluster randomized clinical trial to improve prescribing patterns in ambulatory pediatrics.

June 13, 2007

Medical emergency team: a review of the literature.

March 19, 2008

A model for building a standardized hand-off protocol.

November 8, 2006

Examination of impact of after-hours admissions on hospital resource use, patient outcomes, and costs.

January 11, 2023

Adverse drug event trigger tool: a practical methodology for measuring medication related harm.

March 6, 2005

Iatrogenic illness on a general medical service at a university hospital.

March 27, 2005

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

May 17, 2006

Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions.

March 10, 2010

A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

February 11, 2009

Methicillin-resistant Staphylococcus aureus central line–associated bloodstream infections in US intensive care units, 1997-2007.

February 18, 2009

Reducing surgical specimen errors through multidisciplinary quality improvement.

June 16, 2021

Patient safety professionals as the third victims of adverse events.

June 26, 2019

Minnesota Hospital Association Statewide Project: SAFE from FALLS.

May 23, 2012

Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes.

May 18, 2016

Speaking up about patient-perceived serious visit note errors: patient and family experiences and recommendations.

January 13, 2021

Qualities and attributes of a safe practitioner: identification of safety skills in healthcare.

January 26, 2011

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.

March 17, 2010

Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.

February 13, 2019

Active surveillance using electronic triggers to detect adverse events in hospitalized patients.

June 14, 2006

Medication errors in paediatric outpatients.

September 8, 2010

Using a potentially aggressive/violent patient huddle to improve health care safety.

January 30, 2019

US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients.

August 16, 2006

Teamwork on inpatient medical units: assessing attitudes and barriers.

May 5, 2010

Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams.

April 30, 2008

Impact of implementing alerts about medication black-box warnings in electronic health records.

January 19, 2011

When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record.

June 19, 2019

Second victims need emotional support after adverse events: even in a just safety culture.

April 3, 2019

Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit.

April 2, 2008

Measuring safety climate in health care.

April 19, 2006

Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application.

September 17, 2008

What near misses tell us about risk and safety in mental health care.

November 30, 2011

Medication error prevention by pharmacists.

March 6, 2005

Impact of an obstetrical hospitalist program on the safety events in a mid-sized obstetrical unit.

September 16, 2020

Design of hospital errors and omissions activities that include patient-specific medication related problems.

April 10, 2019

Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error.

October 5, 2016

The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration.

January 6, 2016

Promoting collaboration and transparency in patient safety.

November 29, 2006

Improving medication reconciliation in the outpatient setting.

May 2, 2007

Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries.

November 4, 2009

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

August 18, 2010

The problem with Plan-Do-Study-Act cycles.

February 3, 2016

Putting the 'patient' in patient safety: a qualitative study of consumer experiences.

June 15, 2011

Mary Lanning Memorial Hospital: communication is key.

March 27, 2005

A multisite study of interprofessional teamwork and collaboration on general medical services.

November 25, 2020

The culture of safety: results of an organization-wide survey in 15 California hospitals.

March 6, 2005

The top 10 list for a safe and effective sign-out.

November 5, 2008

Differences in medication reconciliation interventions between six hospitals: a mixed method study.

June 29, 2022

A multifaceted approach to safety: the synergistic detection of adverse drug events in adult inpatients.

September 17, 2008

Mental health of staff working in intensive care during COVID-19.

February 24, 2021

Impact of electronic chemotherapy order forms on prescribing errors at an urban medical center: results from an interrupted time-series analysis.

November 6, 2013

Electronic error-reporting systems: a case study into the impact on nurse reporting of medical errors.

September 11, 2013

Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy.

March 24, 2021

Anesthesia Risk Alert program: a proactive safety initiative.

August 30, 2023

How can we improve the recognition, reporting and resolution of medical device-related incidents in hospitals? A qualitative study of physicians and registered nurses.

July 8, 2015

The quality and safety track: training future physician leaders.

September 4, 2013

Severity of medication administration errors detected by a bar-code medication administration system.

October 1, 2008

The effects of emergency department staff rounding on patient safety and satisfaction.

November 12, 2008

Related Resources

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Medication guides: patient medication information. A proposed rule by the Food and Drug Administration.

June 28, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription and administration process.

March 8, 2023

ISMP survey on tall man (mixed case) lettering to reduce drug name confusion.

November 16, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive task analysis.

March 10, 2021

WebM&M Cases

Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing

June 24, 2020

Medication errors: the year in review.

October 23, 2019

Patient Safety Primers

Patient Safety 101

September 7, 2019

Preventing errors with high-risk medications.

August 28, 2019

Standardising the classification of harm associated with medication errors: the Harm Associated with Medication Error Classification (HAMEC).

May 15, 2019

March 27, 2019

A prescription for enhancing electronic prescribing safety.

December 12, 2018

Are national efforts to reduce drug name confusion paying off?

December 12, 2018

Fixed-dose combination antihypertensives and risk of medication errors.

October 3, 2018

Labeling morphine milligram equivalents on opioid packaging: a potential patient safety intervention.

August 22, 2018

Impact of an antiretroviral stewardship strategy on medication error rates.

July 18, 2018

Medication errors 2018: the year in review.

May 2, 2018

A system-based approach to managing patient safety in ambulatory care (and beyond).

January 10, 2018

Adverse health events related to self-medication practices among elderly: a systematic review.

May 31, 2017

Multicompartment compliance aids in the community: the prevalence of potentially inappropriate medications.

March 1, 2017

Sick children face potentially deadly danger: medication errors.

October 5, 2016

"Use as directed" can cause confusion for both patients and practitioners.

September 14, 2016

The problem with medication reconciliation.

August 31, 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

Value of the pharmacist in the medication reconciliation process.

May 4, 2016

Changing the "working while sick" culture.

February 17, 2016

FDA Drug Safety Communication: FDA warns about prescribing and dispensing errors resulting from brand name confusion with antidepressant Brintellix (vortioxetine) and antiplatelet Brilinta (ticagrelor).

August 12, 2015

ASHP guidelines: minimum standard for ambulatory care pharmacy practice.

July 22, 2015

See More About The Topic

Ambulatory Care

Physicians

Pharmacy

Medication Errors/Preventable Adverse Drug Events

Epidemiology of Errors and Adverse Events

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

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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