Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

Katherine M. Abstoss; Brenda E. Shaw; Tonie A. Owens; Julie L. Juno; Elaine L. Commiskey; Matthew Niedner

Study

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

July 20, 2011

Abstoss KM, Shaw BE, Owens TA, et al. BMJ Qual Saf. 2011;20(11):914-22.

View more articles from the same authors.

This study implemented a series of unit-based safety interventions and discovered notable relationships between improved safety culture and greater medication safety. The authors advocate for interventions that promote a positive safety culture at the unit level.

PubMed citation

Available at

Related Resources From the Same Author(s)

Errors and omissions in anesthesia: a pilot study using a pilot's checklist.

July 13, 2005

The high-reliability pediatric intensive care unit.

May 22, 2013

The Medication Manager: results of a medication at the bedside pilot in a pediatric teaching institution.

June 23, 2010

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

January 19, 2011

Use of error management theory to quantify and characterize residents' error recovery strategies.

January 15, 2020

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

July 12, 2006

Adherence to black box warnings for prescription medications in outpatients.

February 22, 2006

Laboratory session to improve first-year pharmacy students' knowledge and confidence concerning the prevention of medication errors.

November 11, 2009

Accuracy of harm scores entered into an event reporting system.

April 22, 2015

Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed.

October 19, 2016

Improving communication with primary care physicians at the time of hospital discharge.

February 8, 2017

Defining and studying errors in surgical care: a systematic review.

August 17, 2022

Assessment of quality of data provided on Pap test requisitions: implications for quality of care and patient safety.

August 12, 2009

Family support role in hospital rapid response teams: a scoping review.

April 13, 2022

A simulation design for research evaluating safety innovations in anaesthesia.

January 28, 2009

Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions.

June 8, 2011

Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.

September 24, 2014

Parents' perceptions of medical errors.

June 16, 2010

The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.

February 27, 2019

Influences on the adoption of patient safety innovation in primary care: a qualitative exploration of staff perspectives.

August 22, 2018

Use of personal electronic devices by nurse anesthetists and the effects on patient safety.

May 25, 2016

Hospitalized patients' understanding of their plan of care.

January 27, 2010

Wisdom through adversity: learning and growing in the wake of an error.

February 27, 2013

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

November 30, 2016

An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors.

September 6, 2006

Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90).

January 26, 2022

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

January 30, 2019

Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events.

September 29, 2021

Teamwork behaviours and errors during neonatal resuscitation.

March 24, 2010

Improving resident and fellow engagement in patient safety through a graduate medical education incentive program.

January 23, 2019

Improving acceptance of computerized prescribing alerts in ambulatory care.

November 9, 2005

First year nursing students' viewpoints about compromised clinical safety.

July 11, 2012

Interprofessional education in team communication: working together to improve patient safety.

March 27, 2013

Adverse events are common on the intensive care unit: results from a structured record review.

June 20, 2012

Chemotherapy in home care: one team's performance improvement journey toward reducing medication errors.

October 12, 2011

Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.

September 17, 2014

Infection control hazards and near misses reported by nursing students.

January 5, 2011

From research to practice: factors affecting implementation of prospective targeted injury-detection systems.

June 8, 2011

Tubing safety in the obstetric setting: preventing medication errors.

May 6, 2009

Standardizing hand-off processes.

January 3, 2007

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

December 17, 2008

Mandatory presuit mediation: 5-year results of a medical malpractice resolution program.

May 7, 2014

Resident wellness in US ophthalmic graduate medical education: the resident perspective.

May 23, 2018

Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: a systematic review.

June 1, 2016

Clinicians' perceptions of medication errors with opioids in cancer and palliative care services: a priority setting report.

May 30, 2018

Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator.

July 8, 2009

The impact of time at work and time off from work on rule compliance: the case of hand hygiene in health care.

December 3, 2014

Performance-based payment incentives increase burden and blame for hospital nurses.

February 16, 2011

A systematic review of clinical decision support systems for clinical oncology practice.

May 15, 2019

Impact of nursing on hospital patient mortality: a focused review and related policy implications.

February 22, 2006

Preventing medical errors: how to proceed with caution.

September 10, 2014

Adverse events and near miss reporting in the NHS.

August 24, 2005

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

July 29, 2009

Implementation of a modified bedside handoff for a postpartum unit.

June 21, 2017

Stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences.

April 29, 2009

Use of cascading A3s to drive systemwide improvement.

August 2, 2017

Individual surgeon mortality rates: can outliers be detected? A national utility analysis.

November 16, 2016

Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee.

May 7, 2008

Testing a classification model for emergency department errors.

June 28, 2006

Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities.

May 7, 2014

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

February 3, 2016

Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model.

September 8, 2010

Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey.

February 20, 2008

Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.

July 19, 2006

Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability.

November 22, 2006

Assessing legislative potential to institute error transparency: a state comparison of malpractice claims rates.

June 2, 2010

Computerized physician order entry: promise, perils, and experience.

February 12, 2014

Quality improvement and safety in pediatric emergency medicine.

March 6, 2019

Unintentionally retained guidewires: a descriptive study of 73 sentinel events.

March 20, 2019

Developing a national patient safety education framework for Australia.

January 3, 2007

A system-wide initiative to prevent retained vaginal sponges.

September 14, 2011

Safety huddles to proactively identify and address electronic health record safety.

January 25, 2017

Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers.

April 17, 2019

Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls.

May 10, 2017

A systems approach to address the impact of second victim phenomenon.

December 9, 2020

Impact of patient safety climate on infection prevention practices and healthcare worker and patient outcomes.

May 10, 2023

Decreasing prescribing errors in antimicrobial stewardship program-restricted medications.

April 10, 2024

It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure.

November 29, 2023

Nursing strategies to increase medication safety in inpatient settings.

May 25, 2016

Not just "getting by": factors influencing providers' choice of interpreters.

November 12, 2014

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

April 10, 2019

Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study.

June 20, 2018

CDC central-line bloodstream infection prevention efforts produced net benefits of at least $640 million during 1990–2008.

June 18, 2014

Associations between national board exam performance and residency program emphasis on patient safety and interprofessional teamwork.

September 11, 2019

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

SAFER Care: improving caregiver comprehension of discharge instructions.

March 31, 2021

Reducing iatrogenic risks: ICU–acquired delirium and weakness—crossing the quality chasm.

November 24, 2010

Origins of and solutions for neonatal medication-dispensing errors.

January 27, 2010

Improving patient safety in radiology: concepts for a comprehensive patient safety program.

May 12, 2010

Improving patient safety: effects of a safety program on performance and culture in a department of radiology.

July 29, 2009

Errors prevented by and associated with bar-code medication administration systems.

May 2, 2007

Overrides of medication-related clinical decision support alerts in outpatients.

January 8, 2014

Relationship between patient safety climate and standard precaution adherence: a systematic review of the literature.

November 25, 2015

Perception of patient safety culture in pediatric long-term care settings.

February 13, 2019

Interprofessional team collaboration and work environment health in 68 US intensive care units.

November 30, 2022

Effect of hospital follow-up appointment on clinical event outcomes and mortality.

July 14, 2010

Bedside detection of awareness in the vegetative state: a cohort study.

January 30, 2005

Minnesota Hospital Association Statewide Project: SAFE from FALLS.

May 23, 2012

Operating room briefings: working on the same page.

June 14, 2006

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

June 4, 2008

Related Resources

WebM&M Cases

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.

July 31, 2023

WebM&M Cases

Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.

June 28, 2023

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

June 7, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Identification of patient safety threats in a post-intensive care clinic.

May 31, 2023

Undiagnosed and rare diseases in critical care: the role of diagnostic access.

July 27, 2022

Psychological safety in intensive care unit rounding teams.

July 21, 2021

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children.

June 30, 2021

Interventions to reduce pediatric prescribing errors in professional healthcare settings: a systematic review of the last decade.

June 23, 2021

Hospitals look to computers to predict patient emergencies before they happen.

May 22, 2019

Case not closed: prescription errors 12 years after computerized physician order entry implementation.

January 31, 2018

Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis.

April 26, 2017

February 8, 2017

Understanding the nature of medication errors in an ICU with a computerized physician order entry system.

February 11, 2015

Reducing medication errors in critical care: a multimodal approach.

October 1, 2014

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units.

November 6, 2013

Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events.

October 23, 2013

Improving adverse drug event detection in critically ill patients through screening intensive care unit transfer summaries.

July 31, 2013

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

June 12, 2013

Perceptions of risk to patient safety in the pediatric ICU, a study of American pediatric intensivists.

April 17, 2013

Computerized prescriber order entry and opportunities for medication errors: comparison to tradition paper-based order entry.

March 20, 2013

The effects of computerized provider order entry implementation on communication in intensive care units.

February 20, 2013

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

January 30, 2013

Changes in end-user satisfaction with computerized provider order entry over time among nurses and providers in intensive care units.

November 28, 2012

Interventions to reduce medication errors in adult intensive care: a systematic review.

September 26, 2012

Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010.

May 2, 2012

The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU.

April 18, 2012

Implementing an electronic medical record with computerized prescriber order entry at a critical access hospital.

January 4, 2012

What is the value and impact of quality and safety teams? A scoping review.

November 16, 2011

Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans.

November 2, 2011

See More About The Topic

Intensive Care Units

Health Care Providers

Quality and Safety Professionals

Critical Care

Medication Errors/Preventable Adverse Drug Events

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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