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

Jennifer Tjia; Terry Field; Lawrence D. Garber; Jennifer L. Donovan; Abir O. Kanaan; Marsha A. Raebel; Yanfang Zhao; Jacquelyne C. Fuller; Shawn J. Gagne; Shira H. Fischer; Jerry H. Gurwitz

Study

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

August 11, 2010

Tjia J, Field T, Garber LD, et al. Am J Manag Care. 2010;16(7):489-96.

View more articles from the same authors.

This study reports on the development of standards for laboratory monitoring of high-risk medications (such as anticoagulants) in ambulatory care. Pilot testing revealed that the developed guidelines were not being consistently followed, with infrequently prescribed medications most likely to be monitored inappropriately.

PubMed citation

Available at

Related Resources From the Same Author(s)

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

November 13, 2013

Dementia and risk of adverse warfarin-related events in the nursing home setting.

November 21, 2012

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

February 23, 2011

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review.

November 10, 2010

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety.

September 9, 2009

The costs associated with adverse drug events among older adults in the ambulatory setting.

December 7, 2005

Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets.

August 30, 2017

Strategies for detecting adverse drug events among older persons in the ambulatory setting.

March 6, 2005

Adverse drug events resulting from patient errors in older adults.

March 7, 2007

Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency.

July 22, 2009

Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

March 6, 2005

FDA drug prescribing warnings: is the black box half empty or half full?

December 7, 2005

Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders.

November 7, 2007

Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications.

March 18, 2009

Responsible e-prescribing needs e-discontinuation.

February 15, 2017

The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review.

April 16, 2008

Disclosure of medical errors: what factors influence how patients respond?

June 21, 2006

Prescribers' responses to alerts during medication ordering in the long term care setting.

August 30, 2006

An exploration of safety climate in nursing homes.

August 8, 2012

The safety of warfarin therapy in the nursing home setting.

June 13, 2007

Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care.

January 18, 2006

Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care.

October 26, 2005

An interview with Jerry Gurwitz.

November 29, 2006

Beyond medication reconciliation: the correct medication list.

May 3, 2017

In the eye of the storm: the role of the pharmacist in medication safety during the COVID-19 pandemic at an urban teaching hospital.

December 23, 2020

Randomized trial to improve prescribing safety in ambulatory elderly patients.

September 12, 2007

Drug shortages and clinicians: no time for complacency.

October 3, 2012

The association of nursing home characteristics and quality with adverse events after a hospitalization.

April 28, 2021

Adverse events in long-term care residents transitioning from hospital back to nursing home.

August 7, 2019

What do medical records tell us about potentially harmful co-prescribing?

July 18, 2007

Evaluation of laboratory monitoring alerts within a computerized physician order entry system for medication orders.

September 20, 2006

Randomized trial to improve prescribing safety during pregnancy.

July 11, 2007

Health plan members' views about disclosure of medical errors.

March 6, 2005

Communicating with patients about medical errors: a review of the literature.

March 6, 2005

Beyond the prescription: medication monitoring and adverse drug events in older adults.

August 31, 2011

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

February 11, 2009

The incidence of adverse drug events in two large academic long-term care facilities.

April 15, 2005

Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.

June 22, 2005

Medication errors in the homes of children with chronic conditions.

January 30, 2005

Potential medication dosing errors in outpatient pediatrics.

January 11, 2006

Medication histories in critically ill patients completed by pharmacy personnel.

August 7, 2019

Adverse event rates as measures of hospital performance.

September 21, 2011

Standardized assessment of medication reconciliation in post-acute care.

April 27, 2022

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.

December 21, 2005

Medication discrepancies upon hospital to skilled nursing facility transitions.

April 29, 2009

Intersystem medical error discovery: a document analysis of ethical guidelines.

January 12, 2022

Passing the baton: a grounded practical theory of handoff communication between multidisciplinary providers in two Department of Veterans Affairs outpatient settings.

September 5, 2012

A theoretical framework and competency-based approach to improving handoffs.

May 28, 2008

Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery.

October 19, 2016

Harmful medication errors in children: a 5-year analysis of data from the USP's MEDMARX(R) program.

August 2, 2006

Residents' response to duty-hour regulations—a follow-up national survey.

June 6, 2012

Inappropriate preinjury warfarin use in trauma patients: a call for a safety initiative.

May 18, 2016

Medication errors among adults and children with cancer in the outpatient setting.

January 14, 2009

The "July phenomenon": is trauma the exception?

October 14, 2009

Resident uncertainty in clinical decision making and impact on patient care: a qualitative study.

April 16, 2008

Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record.

July 22, 2009

The 2011 duty-hour requirements—a survey of residency program directors.

February 27, 2013

Residents' perspectives on ACGME regulation of supervision and duty hours—a national survey.

December 8, 2010

Transforming healthcare: a safety imperative.

December 9, 2009

Frequency of failure to inform patients of clinically significant outpatient test results.

June 24, 2009

Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative study.

June 3, 2015

Non-intercepted dose errors in prescribing antineoplastic treatment: a prospective, comparative cohort study.

March 11, 2015

Providers' and patients' perspectives on diagnostic errors in the acute care setting.

February 15, 2023

Variation in caregiver perceptions of teamwork climate in labor and delivery units.

July 5, 2006

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems.

January 28, 2015

Patient-led training on patient safety: a pilot study to test the feasibility and acceptability of an educational intervention.

September 4, 2013

Health outcomes associated with potentially inappropriate medication use in older adults.

April 2, 2008

Standardizing concentrations of adult drug infusions in Indiana.

June 7, 2017

Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit.

December 16, 2009

Patient-centered approach for improving prescription drug warning labels.

September 24, 2008

Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center

January 15, 2020

Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery.

January 13, 2010

Motivational influences on anaesthetists' use of practice guidelines.

May 13, 2009

Critical Issues in Food Allergy: A National Academies Consensus Report.

September 6, 2017

Surgical complications and their implications for surgeons' well-being.

January 22, 2014

Development of a standardized, citywide process for managing smart-pump drug libraries.

August 1, 2018

The evolution of a safety culture.

October 7, 2015

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

July 22, 2015

Evaluation of frequency of paediatric oral liquid medication dosing errors by caregivers: amoxicillin and josamycin.

March 9, 2016

Health care professionals' perceptions of unprofessional behaviour in the clinical workplace.

March 1, 2023

Going to the COVID-19 Gemba: using observation and high reliability strategies to achieve safety in a time of crisis.

June 10, 2020

Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic.

October 1, 2014

Medication reconciliation in ambulatory oncology.

December 5, 2007

Relationship between patient complaints and surgical complications.

February 15, 2006

An overview of intravenous-related medication administration errors as reported to MEDMARX(R), a national medication error-reporting program.

February 8, 2006

Clinic design for safety during the pandemic: safety or teamwork, can we only pick one?

May 11, 2022

(How) do we learn from errors? A prospective study of the link between the ward's learning practices and medication administration errors.

August 21, 2013

Patient safety culture transformation in a children's hospital: an interprofessional approach.

April 30, 2014

Predictors of treatment error for children with uncomplicated malaria seen as outpatients in Blantyre district, Malawi.

September 13, 2006

Prevalence of adverse events in the hospitals of five Latin American countries: results of the 'Iberoamerican Study of Adverse Events' (IBEAS).

August 10, 2011

Using a network organisational architecture to support the development of Learning Healthcare Systems.

February 21, 2018

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

March 13, 2019

Rapid response teams and failure to rescue: one community's experience.

June 27, 2012

Examining the validity of AHRQ's Patient Safety Indicators (PSIs): is variation in PSI composite score related to hospital organizational factors?

November 26, 2014

Artificial intelligence systems for complex decision-making in acute care medicine: a review.

March 13, 2019

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.

October 26, 2022

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

December 15, 2010

A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures.

March 4, 2009

Analysing potential harm in Australian general practice: an incident-monitoring study.

March 27, 2005

Related Resources

ISMP Survey on High-Alert Medications in Acute Care Settings.

September 11, 2023

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

August 23, 2023

American Geriatrics Society 2023 updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

August 16, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017.

July 5, 2023

Medication use evaluation of high-dose long-term opioid de-prescribing in multiple Veterans Affairs medical centers.

January 18, 2023

Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action.

September 21, 2022

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.

June 29, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.

May 17, 2021

Association between in-clinic opioid administration and discharge opioid prescription in urgent care: a retrospective cohort study.

February 17, 2021

Transforming the medication regimen review process using telemedicine to prevent adverse events.

December 16, 2020

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.

July 29, 2020

Key potentially inappropriate drugs in pediatrics: the KIDs list.

June 24, 2020

Reduce the likelihood of patient harm associated with the use of anticoagulant therapy: commentary from the Anticoagulation Forum on the Updated Joint Commission NPSG.03.05.01 Elements of Performance

March 4, 2020

Never events in UK general practice: A survey of the views of general practitioners on their frequency and acceptability as a safety improvement approach

December 11, 2019

Preventing errors with high-risk medications.

August 28, 2019

Managing the risks of direct oral anticoagulants.

August 7, 2019

Independent double checks: worth the effort if used judiciously and properly.

June 19, 2019

American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

June 12, 2019

Reducing avoidable medication-related harm: what will it take?

May 8, 2019

Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.

November 7, 2018

ISMP's List of High-Alert Medications in Acute Care Settings.

August 23, 2018

Patient perceptions of receiving test results via online portals: a mixed-methods study.

January 17, 2018

Clinician perspectives on the management of abnormal subcritical tests in an urban academic safety-net health care system.

October 4, 2017

Nil per os orders for imaging: a teachable moment.

September 27, 2017

ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults.

June 7, 2017

Electronic detection of delayed test result follow-up in patients with hypothyroidism.

February 15, 2017

Standardization of compounded oral liquids for pediatric patients in Michigan.

August 31, 2016

Patient identification and tube labelling—a call for harmonisation.

August 10, 2016

See More About The Topic

Ambulatory Care

Health Care Providers

Quality and Safety Professionals

Pathology and Laboratory Medicine

Pharmacy

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

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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