Developing a comprehensive framework of safeguarding strategies to address anticipated errors with organizational high-alert medications.

Jennifer P Booth; Amber D Hartman

Commentary

Developing a comprehensive framework of safeguarding strategies to address anticipated errors with organizational high-alert medications.

January 31, 2024

Booth JP, Hartman AD. Hosp Pharm. 2024;59(1):47-55.

View more articles from the same authors.

Intensive strategies are required to prevent high-risk medication errors from reaching the patient. This article describes the development of a framework to identify common causes of medication errors and human factors-related strategies to prevent harm such as manufacturer or organizational premixed/prefilled products and separate storage.

PubMed citation

Available at

Related Resources From the Same Author(s)

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

March 24, 2021

Families as partners in hospital error and adverse event surveillance.

March 8, 2017

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.

December 19, 2018

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Changes in medical errors after implementation of a handoff program.

November 12, 2014

Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment.

July 14, 2021

Readiness of US general surgery residents for independent practice.

October 4, 2017

Association of patient and family reports of hospital safety climate with language proficiency in the US.

June 29, 2022

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice.

August 17, 2011

I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources.

March 10, 2019

I-PASS mentored implementation handoff curriculum: champion training materials.

March 13, 2019

Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety.

July 19, 2023

Effect of promoting high-quality staff interactions on fall prevention in nursing homes: a cluster-randomized trial.

October 25, 2017

Preventable adverse drug events: descriptive epidemiology.

November 13, 2019

Family safety reporting in hospitalized children with medical complexity.

July 20, 2022

Recommendations to improve the usability of drug–drug interaction clinical decision support alerts.

November 25, 2015

Family safety reporting in medically complex children: parent, staff, and leader perspectives.

July 6, 2022

In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.

September 6, 2023

Failures in the respectful care of critically ill patients.

October 10, 2018

Development, implementation, and dissemination of the I-PASS Handoff Curriculum: a multisite educational intervention to improve patient handoffs.

June 25, 2014

The impact of computerized provider order entry on medication errors in a multispecialty group practice.

February 3, 2010

Inappropriate medications in elderly ICU survivors: where to intervene?

June 29, 2011

Journal Article

Study

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

March 29, 2023

Fostering a just culture in healthcare organizations: experiences in practice.

August 31, 2022

Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care.

August 10, 2022

Patient perspectives on the use of artificial intelligence for skin cancer screening: a qualitative study.

April 1, 2020

Improving communication and teamwork during labor: a feasibility, acceptability, and safety study.

March 16, 2022

Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations.

August 17, 2022

Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.

January 25, 2017

Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.

June 24, 2015

Investigating teamwork in the operating room: engaging stakeholders and setting the agenda.

October 19, 2016

Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.

July 26, 2017

Am I safe? An interpretative phenomenological analysis of vulnerability as experienced by patients with complications following surgery.

January 18, 2023

Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis.

May 13, 2020

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

July 19, 2006

Crowding in the Emergency Department: Challenges for the Care of Children.

March 15, 2023

Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications.

November 13, 2013

Preventing home medication administration errors.

March 14, 2022

A safety evaluation of the impact of maternity-orientated human factors training on safety culture in a tertiary maternity unit.

June 19, 2019

What patients think doctors know: beliefs about provider knowledge as barriers to safe medication use.

August 14, 2013

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study.

July 22, 2020

Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting.

August 11, 2010

Improving care transitions: current practice and future opportunities for pharmacists.

December 5, 2012

Hospital cultural competency and attributes of patient safety culture: a study of U.S. hospitals.

November 17, 2021

Survey of nurses' experiences applying The Joint Commission's medication management titration standards.

November 3, 2021

Perceptions of nurses who are second victims in a hospital setting.

December 22, 2021

Use of a structured approach and virtual simulation practice to improve diagnostic reasoning.

February 23, 2022

Implementation of the safety huddle.

February 8, 2017

Year-end resident clinic handoffs: narrative review and recommendations for improvement.

February 15, 2017

Resource-based view on safety culture's influence on hospital performance: the moderating role of electronic health record implementation.

September 19, 2018

Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting.

June 25, 2014

Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout.

June 4, 2014

Burnout in the NICU setting and its relation to safety culture.

May 7, 2014

Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations.

March 10, 2010

The effect of multidisciplinary care teams on intensive care unit mortality.

March 3, 2010

Barriers and facilitators to nursing handoffs: recommendations for redesign.

June 9, 2010

Speaking up and sharing information improves trainee neonatal resuscitations.

December 12, 2012

What do patients think about year-end resident continuity clinic handoffs?: a qualitative study.

May 22, 2013

Patient safety outcomes after two years of an enhanced internal medicine residency clinic handoff.

March 28, 2018

Resident shift handoff strategies in US internal medicine residency programs.

March 14, 2018

Reducing serious safety events and priority hospital-acquired conditions in a pediatric hospital with the implementation of a patient safety program.

June 6, 2018

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety.

March 21, 2018

Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial.

January 17, 2018

Nighttime and weekend medication error rates in an inpatient pediatric population.

December 15, 2010

Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019.

January 4, 2021

COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected.

August 19, 2020

Targeting zero harm: a stretch goal that risks breaking the spring.

August 12, 2020

Inpatient patient safety events in vulnerable populations: a retrospective cohort study.

November 18, 2020

How safe are paediatric emergency departments? A national prospective cohort study.

August 3, 2022

Success of a resident-led safety council: a model for satisfying CLER Pathways to Excellence patient safety goals.

October 9, 2019

Patient outcomes after the introduction of statewide ICU nurse staffing regulations.

September 26, 2018

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.

March 16, 2016

Multicenter study to evaluate the benefits of technology-assisted workflow on i.v. room efficiency, costs, and safety.

June 26, 2019

Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force.

January 19, 2011

Telemedicine consultations and medication errors in rural emergency departments.

December 11, 2013

Redesigning rounds in the ICU: standardizing key elements improves interdisciplinary communication.

October 3, 2018

Opioid abuse and poisoning: trends in inpatient and emergency department discharges.

November 1, 2017

Associations between organizational communication and patients' experience of prolonged emotional impact following medical errors.

April 17, 2024

Inappropriate diagnosis of pneumonia among hospitalized adults.

April 10, 2024

Development and evaluation of I-PASS-to-PICU: a standard electronic template to improve referral communication for inter-facility transfers to the pediatric intensive care unit.

March 27, 2024

Assessment of unintentional duplicate orders by emergency department clinicians before and after implementation of a visual aid in the electronic health record ordering system.

January 22, 2020

Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory.

December 3, 2008

Pediatric rapid response teams in the academic medical center.

January 3, 2007

No excuses: the reality that demands action.

September 1, 2005

High fidelity simulation-based training in neonatal nursing.

March 6, 2005

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda.

March 29, 2023

Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review.

May 12, 2021

The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors.

February 10, 2021

Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.

December 16, 2020

A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain.

July 14, 2021

Structural racism and the COVID-19 experience in the United States.

July 7, 2021

Safety culture as a patient safety practice for alarm fatigue.

October 13, 2021

Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study.

December 8, 2008

Modes of failure in venous thromboembolism prophylaxis.

September 28, 2022

Parent experiences with the process of sharing inpatient safety concerns for children with medical complexity: a qualitative analysis.

August 9, 2023

A multi-method exploratory evaluation of a service designed to improve medication safety for patients with monitored dosage systems following hospital discharge.

October 25, 2023

A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings.

October 4, 2023

Related Resources

WebM&M Cases

Verbal Orders and Medication Overrides: A Dangerous Combination

April 24, 2024

Implement strategies to prevent persistent medication errors and hazards: 2024.

April 3, 2024

Designing human-centered AI to prevent medication dispensing errors: focus group study with pharmacists.

March 20, 2024

Time for prefilled syringes - everywhere.

March 13, 2024

Targeted Medication Safety Best Practices for Hospitals.

February 22, 2024

The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial.

February 14, 2024

Risks to Medication Delivery Using Ambulatory Infusion Pumps – Design and Usability in Inpatient Settings.

February 14, 2024

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review.

December 6, 2023

Temporarily holding medication orders safely in order to prevent patient harm.

November 1, 2023

WebM&M Cases

Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose

October 31, 2023

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

August 23, 2023

Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.

August 9, 2023

A hard look at hard stops and workarounds in the acute care setting.

July 12, 2023

ISMP Targeted Medication Safety Best Practices for Community Pharmacy.

April 19, 2023

Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety.

February 22, 2023

Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.

February 1, 2023

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

February 1, 2023

Weight and size descriptors for drug dosing: too many options and too many errors.

January 11, 2023

Preventing errors when preparing and administering medications via enteral feeding tubes.

December 7, 2022

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

November 16, 2022

Safety considerations for challenges when using smart infusion pumps.

November 2, 2022

Free-text computerized provider order entry orders used as workaround for communicating medication information.

August 31, 2022

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

August 10, 2022

The electronic prescribing of subcutaneous infusions: a before-and-after study assessing the impact upon patient safety and service efficiency.

June 15, 2022

ASHP Guidelines on the Safe Use of Automated Compounding Devices for the Preparation of Parenteral Nutrition Admixtures.

June 15, 2022

At US hospitals, a drug mix-up is just a few keystrokes away.

May 11, 2022

Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

February 23, 2022

Pharmacist and prescriber responsibilities for avoiding prescription drug misuse.

July 28, 2021

Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems.

March 3, 2021

See More About The Topic

Hospitals

Hospital Medicine

Hospital Pharmacy

Ordering/Prescribing Errors

Dispensing Errors

Developing a comprehensive framework of safeguarding strategies to address anticipated errors with organizational high-alert medications.

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Developing a comprehensive framework of safeguarding strategies to address anticipated errors with organizational high-alert medications.

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

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