Improving self-reporting of adverse drug events in a West Virginia hospital.

Charles P Schade; Karen Hannah; Patricia Ruddick; Celesta Starling; John Brehm

Study

Improving self-reporting of adverse drug events in a West Virginia hospital.

October 4, 2006

Schade CP, Hannah K, Ruddick P, et al. Am J Med Qual. 2006;21(5):335-41.

View more articles from the same authors.

This AHRQ–funded research team determined that incident reports were made for less than 4% of adverse drug events (ADEs) involving rescue drugs to treat the ADE.

PubMed citation

Available at

Related Resources From the Same Author(s)

E-prescribing, efficiency, quality: lessons from the computerization of UK family practice.

September 20, 2006

Outcome of 6 years of protocol use for preventing wrong site office surgery.

August 24, 2011

Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal.

January 30, 2005

Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence.

February 26, 2020

Transformative learning in a professional development course aimed at addressing disruptive physician behavior: a composite case study.

January 23, 2013

Should electronic differential diagnosis support be used early or late in the diagnostic process? A multicentre experimental study of Isabel.

October 27, 2021

Development of a self-report instrument to measure patient safety attitudes, skills, and knowledge.

February 11, 2009

Reducing adverse events in blood transfusion.

October 5, 2005

Medication error in the care of HIV/AIDS patients: electronic surveillance, confirmation, and adverse events.

September 7, 2005

Do physicians know when their diagnoses are correct? Implications for decision support and error reduction.

September 7, 2005

Patient-reported safety and quality of care in outpatient oncology.

February 7, 2007

The impact of computerised physician order entry and clinical decision support on pharmacist–physician communication in the hospital setting: a qualitative study.

February 27, 2019

Collaboration with regulators to support quality and accountability following medical errors: the communication and resolution program certification pilot.

September 21, 2016

Family alert: implementing direct family activation of a pediatric rapid response team.

October 28, 2009

Closing the disclosure gap: medical errors in pediatrics.

March 27, 2019

Compensation of chief executive officers at nonprofit US hospitals.

October 30, 2013

North Mississippi Medical Center: a focus on quality, safety, and financial critical success factors.

October 12, 2005

Nurse interrupted: development of a realistic medication administration simulation for undergraduate nurses.

August 26, 2015

Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer.

September 8, 2010

Medication errors in a pharmacy-based bar-code-repackaging center.

January 25, 2006

Catheter-associated urinary tract infection reduction in a pediatric safety engagement network.

September 30, 2020

Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.

July 28, 2010

Creating a fair and just culture: one institution's path toward organizational change.

October 10, 2007

Patients as teachers: a randomised controlled trial on the use of personal stories of harm to raise awareness of patient safety for doctors in training.

September 3, 2014

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle.

September 1, 2021

Opportunities to improve diagnosis in emergency transfers to the pediatric intensive care unit.

August 30, 2023

Infusing fun into quality and safety initiatives.

January 30, 2013

Novel approach to cardiac alarm management on telemetry units.

February 19, 2014

Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions?

June 14, 2017

Association of primary care clinic appointment time with opioid prescribing.

September 11, 2019

Increasing demands for quality measurement.

November 27, 2013

Adverse drug events in hospitalized cardiac patients.

November 7, 2007

Advanced practice nursing students' identification of patient safety issues in ambulatory care.

April 10, 2013

Are we heeding the warning signs? Examining providers' overrides of computerized drug–drug interaction alerts in primary care.

January 22, 2014

Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in a pediatric ICU.

February 5, 2014

Serious hazards of transfusion (SHOT) haemovigilance and progress is improving transfusion safety.

November 20, 2013

Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities.

October 19, 2022

Advancing the next generation of handover research and practice with cognitive load theory.

January 27, 2016

Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review.

June 12, 2019

High rates of adverse drug events in a highly computerized hospital.

May 25, 2005

Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention.

February 15, 2017

Health literacy and quality: focus on chronic illness care and patient safety.

November 18, 2009

Inappropriate opioid prescription after surgery.

May 29, 2019

The effect of contact precautions on frequency of hospital adverse events.

December 9, 2015

Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care.

February 7, 2007

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

July 15, 2015

The effects of three consecutive 12-hour shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: a quasi-experimental study.

October 20, 2021

Experiences of transgender people reviewing their electronic health records, a qualitative study.

June 29, 2022

Delay or avoidance of medical care because of COVID-19-related concerns--United States, June 2020.

October 7, 2020

Physician engagement in malpractice risk reduction: a UPHS case study.

August 29, 2018

Patient safety issues in advanced practice nursing students' care settings.

November 9, 2011

Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs' computerized patient record system.

September 17, 2008

Comparison of physician and computer diagnostic accuracy.

October 19, 2016

Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis.

June 26, 2013

Evaluation of symptom checkers for self diagnosis and triage: audit study.

July 29, 2015

Anticoagulation-associated adverse drug events.

December 14, 2011

A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement.

May 25, 2016

Variability in collection and use of race/ethnicity and language data in 93 pediatric hospitals.

October 14, 2020

Patient safety skills in primary care: a national survey of GP educators.

February 4, 2015

High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care.

February 25, 2009

Attitudinal changes resulting from repetitive training of operating room personnel using high-fidelity simulation at the point of care.

September 16, 2009

Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room.

October 8, 2008

Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012.

December 7, 2016

Empowering informal caregivers with health information: OpenNotes as a safety strategy.

March 14, 2018

Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation.

February 11, 2009

Implementing universal suicide risk screening in a pediatric hospital.

August 18, 2021

Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.

October 13, 2010

Impact of extended-duration shifts on medical errors, adverse events, and attentional failures.

December 13, 2006

Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns.

January 30, 2013

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

October 13, 2021

Implicit bias and caring for diverse populations: pediatric trainee attitudes and gaps in training.

September 22, 2021

Integrating and evaluating the data quality and utility of smart pump information in detecting medication administration errors: evaluation study.

November 4, 2020

Importance of safety climate, teamwork climate and demographics: understanding nurses, allied health professionals and clerical staff perceptions of patient safety.

January 30, 2019

Pediatric trainee perspectives on the decision to disclose medical errors.

March 30, 2022

Patient safety: do nursing and medical curricula address this theme?

June 1, 2005

How to perform a root cause analysis for workup and future prevention of medical errors: a review.

October 19, 2016

Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study.

October 23, 2013

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.

January 2, 2008

The human face of simulation: patient-focused simulation training.

October 18, 2006

Patient reports of preventable problems and harms in primary health care.

March 6, 2005

Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies.

September 9, 2020

Patient Safety Innovations

The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis

September 29, 2021

January 25, 2023

Interprofessional training and communication practices among clinicians in the postoperative ICU handoff.

April 28, 2021

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

August 10, 2011

Special report: suicidal ideation among American surgeons.

February 2, 2011

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

January 11, 2006

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

December 16, 2009

Surgical team behaviors and patient outcomes.

October 1, 2008

Extended work duration and the risk of self-reported percutaneous injuries in interns.

September 6, 2006

Acute care nurses' perceptions of leadership, teamwork, turnover intention and patient safety - a mixed methods study.

October 13, 2021

What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care.

April 1, 2020

Evidence of respiratory infection transmission within physician offices could inform outpatient infection control.

September 1, 2021

So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization.

July 5, 2023

Effectiveness of acute care remote triage systems: a systematic review.

February 5, 2020

Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education.

May 17, 2017

'I'm smiling under here': Masks, plexiglass and questions the norm as hospitals lure patients back in COVID-19 era.

June 17, 2020

Effective communication with primary care providers.

October 1, 2014

Rural nurses' safeguarding work: reembodying patient safety.

June 15, 2011

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

Related Resources

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

National Diabetes Inpatient Audit -- Harms.

July 8, 2021

Nurse burnout predicts self-reported medication administration errors in acute care hospitals.

January 20, 2021

An in situ simulation program: a quantitative and qualitative prospective study identifying latent safety threats and examining participant experiences.

January 20, 2021

Predictors of nursing home nurses' willingness to report medication near-misses.

May 13, 2020

Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt.

November 13, 2019

Using incident reports to assess communication failures and patient outcomes.

April 17, 2019

Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery.

March 13, 2019

Comparing the outcomes of reporting and trigger tool methods to capture adverse events in the emergency department.

February 27, 2019

Frequency of medication error in pediatric anesthesia: a systematic review and meta-analytic estimate.

December 5, 2018

Evaluation of accuracy of IHI Trigger Tool in identifying adverse drug events: a prospective observational study.

September 12, 2018

Understanding interrater reliability and validity of risk assessment tools used to predict adverse clinical events.

March 15, 2017

Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes.

August 31, 2016

Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports.

August 3, 2016

Alternative perspectives of safety in home delivered health care: a sequential exploratory mixed method study.

June 29, 2016

5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data.

September 24, 2014

The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings.

September 10, 2014

Identifying facilitators and barriers for patient safety in a medicine label design system using patient simulation and interviews.

July 23, 2014

Look alike/sound alike drugs: a literature review on causes and solutions.

June 11, 2014

Hospital deaths in patients with sepsis from 2 independent cohorts.

June 4, 2014

Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.

May 14, 2014

The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program.

May 7, 2014

Patient-as-observer approach: an alternative method for hand hygiene auditing in an ambulatory care setting.

April 30, 2014

Who do hospital physicians and nurses go to for advice about medications? A social network analysis and examination of prescribing error rates.

April 16, 2014

Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.

February 5, 2014

Diagnostic Error in Medicine.

September 25, 2013

Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients.

September 25, 2013

Clinical relevance of and risk factors associated with medication administration time errors.

July 10, 2013

Pediatric emergency nurses self-reported medication safety practices.

June 26, 2013

See More About The Topic

Quality and Safety Professionals

Improving self-reporting of adverse drug events in a West Virginia hospital.

The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis

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

Improving self-reporting of adverse drug events in a West Virginia hospital.

The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis

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

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