Quest for the ideal: a redesign of the medication use system.

Deborah Dang; Robert Feroli; Carla Gill; Lori A Paine; Kenneth Shermock; Jeannette Suflita; Jo M Walrath

Commentary

Quest for the ideal: a redesign of the medication use system.

January 31, 2007

Dang D, Feroli R, Gill C, et al. J Nurs Care Qual. 2007;22(1):11-19.

View more articles from the same authors.

The authors describe the interdisciplinary planning and redesign of their hospital's medication administration system.

PubMed citation

Available at

Related Resources From the Same Author(s)

An organizational assessment of disruptive clinician behavior: findings and implications.

April 24, 2013

Hospital RNs' experiences with disruptive behavior: a qualitative study.

April 7, 2010

Development and validation of the Johns Hopkins Disruptive Clinician Behavior Survey.

August 27, 2014

Improving patient safety and communication through care rounds in a pediatric oncology outpatient clinic.

March 28, 2007

Health care workers as second victims of medical errors.

May 11, 2011

Re-examining high reliability: actively organising for safety.

May 18, 2016

Examining medication errors in a tertiary hospital.

December 20, 2006

Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study.

October 26, 2016

Medical errors: where are we now?

November 15, 2006

Identifying high-alert medications in a university hospital by applying data from the medication error reporting system.

August 16, 2017

Nurses' perceptions of causes of medication errors and barriers to reporting.

December 20, 2006

"That was a close call": endorsing a broad definition of near misses in health care.

October 2, 2013

A framework for operationalizing risk: a practical approach to patient safety.

May 2, 2018

Do clinician disruptive behaviors make an unsafe environment for patients?

October 7, 2015

Triggers contributing to health care clinicians' disruptive behaviors.

September 16, 2020

Associations between safety culture and employee engagement over time: a retrospective analysis.

July 1, 2015

Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety culture in a surgical inpatient unit.

June 2, 2010

The Johns Hopkins Hospital: identifying and addressing risks and safety issues.

March 6, 2005

Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery.

April 3, 2005

Paying the piper: investing in infrastructure for patient safety.

June 4, 2008

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

December 22, 2010

Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action.

December 6, 2017

Nurse–pharmacist collaboration on medication reconciliation prevents potential harm.

August 22, 2012

A web-based tool for the Comprehensive Unit-based Safety Program (CUSP).

March 15, 2006

Operating management system for high reliability: leadership, accountability, learning and innovation in healthcare.

September 5, 2018

Development and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking among medical students.

April 18, 2012

Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers.

November 9, 2016

Latent risk assessment tool for health care leaders.

April 25, 2018

A check-up for safety culture in "my patient care area."

November 14, 2007

The Armstrong Institute: an academic institute for patient safety and quality improvement, research, training, and practice.

June 10, 2015

Implementation of patient centeredness to enhance patient safety.

January 31, 2006

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital.

August 22, 2018

Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.

August 31, 2016

The safety culture in a children's hospital.

July 12, 2006

Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center.

March 6, 2005

Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic.

October 28, 2020

A model for the departmental quality management infrastructure within an academic health system.

September 28, 2016

Patient safety: planting the seed.

July 20, 2005

A nurse-driven system for improving patient quality outcomes.

April 12, 2006

Novel analysis of clinically relevant diagnostic errors in point-of-care devices.

October 19, 2011

Near-miss transcription errors: a comparison of reporting rates between a novel error-reporting mechanism and a current formal reporting system.

March 18, 2015

The Shift Coupon: an innovative method to monitor adverse events.

January 18, 2006

COVID-19: the dark side and the sunny side for patient safety.

October 14, 2020

Taking aim at infusion confusion.

April 12, 2006

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

December 14, 2022

Structural empowerment, Magnet hospital characteristics, and patient safety culture: making the link.

April 5, 2006

Patient safety in nursing practice.

July 20, 2005

Am I safe here? Improving patients' perceptions of safety in hospitals.

January 25, 2006

Pharmacist-supported medication review training for general practitioners: feasibility and acceptability.

December 6, 2006

How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety?

December 7, 2022

Developing a patient safety surveillance system to identify adverse events in the intensive care unit.

June 16, 2010

Adverse drug event reporting in intensive care units: a survey of current practices.

August 2, 2006

Medication reconciliation in the acute care setting: opportunity and challenge for nursing.

May 4, 2005

Crushing or splitting medications: unrecognized hazards.

January 25, 2012

The impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review.

June 22, 2016

Fall prevention with the Smart Socks System reduces hospital fall rates.

September 7, 2022

Evaluation of an automated surveillance system using trigger alerts to prevent adverse drug events in the intensive care unit and general ward.

April 1, 2015

A comparison of voluntarily reported medication errors in intensive care and general care units.

March 24, 2010

Best practices in medication administration: preventing adverse drug events in perinatal settings.

March 7, 2007

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

December 16, 2020

Can you read this drug label?

August 3, 2011

Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation.

October 26, 2022

Determining a patient's comfort in inquiring about healthcare providers' hand-washing behavior.

June 12, 2013

Clinical decision support for drug related events: moving towards better prevention.

December 21, 2016

Analysis of risk factors for adverse drug events in critically ill patients.

April 11, 2012

Multiprofessional survey of protocol use in the intensive care unit.

November 14, 2012

Adverse-drug-event rates for high-cost and high-use drugs in the intensive care unit.

October 11, 2006

Identification of adverse events in ground transport emergency medical services.

September 14, 2011

Themed Issue on Innovations in Medication Safety.

August 22, 2018

The APSF: 20-year anniversary of the first patient safety organization: past, present & future.

June 27, 2007

Recommendations for the safe, effective use of adaptive CDS in the US healthcare system: an AMIA position paper.

April 21, 2021

Medication errors during medical emergencies in a large, tertiary care, academic medical center.

June 13, 2012

Evidence-based guidelines for fatigue risk management in EMS: formulating research questions and selecting outcomes.

December 7, 2016

Influencing a culture of quality and safety through huddles.

November 9, 2022

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

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

July 31, 2013

The cost of opioid–related adverse drug events.

October 8, 2014

Building nursing intellectual capital for safe use of information technology: a systematic review.

February 9, 2011

Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards.

June 19, 2013

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

August 22, 2018

Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency.

January 27, 2016

Impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency: a systematic review.

September 16, 2020

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety.

May 5, 2021

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

January 18, 2023

Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit.

January 16, 2008

Evidence-based guidelines for fatigue risk management in emergency medical services.

March 14, 2018

Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.

January 30, 2005

Randomized controlled evaluation of an insulin pen storage policy.

February 14, 2018

Implementing the clinical occurrence reporting and learning system: a double-loop learning incident reporting system in long-term care.

March 24, 2021

Staffing, teamwork and scope of practice: analysis of the association with patient safety in the context of rehabilitation.

December 15, 2021

Physician attitudes toward family-activated medical emergency teams for hospitalized children.

April 2, 2014

Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning.

January 11, 2023

Perinatal clinical decision support system: a documentation tool for patient safety.

October 10, 2007

Emerging issues and challenges for improving patient safety in mental health: a qualitative analysis of expert perspectives.

March 2, 2011

Registered nurses' judgments of the classification and risk level of patient care errors.

October 19, 2011

Error training: missing link in surgical education.

April 11, 2012

Working conditions that support patient safety.

October 12, 2005

Confronting unprofessional behaviour in medicine.

March 28, 2018

Safety in the home healthcare sector: development of a new household safety checklist.

May 9, 2012

Related Resources

Interview

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

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

February 22, 2023

FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters.

January 26, 2023

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

January 11, 2023

Prevent administration of ear drops into the eyes.

December 14, 2022

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

November 16, 2022

Intravenous smart pumps at the point of care: a descriptive, observational study.

October 12, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Sentinel Event Alert 63: optimizing smart infusion pump safety with DERS.

April 21, 2021

Crossing academic boundaries for diagnostic safety: 10 complex challenges and potential solutions from clinical perspectives and high-reliability organizing principles.

March 24, 2021

From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment.

February 10, 2021

Avoiding a second wave of medical errors: the importance of human factors in the context of a pandemic.

August 26, 2020

Patient Safety Primers

COVID-19: Team and Human Factors to Improve Safety

July 30, 2020

Systemic defenses to prevent intravenous medication errors in hospitals: a systematic review.

July 1, 2020

An integrative total worker health framework for keeping workers safe and healthy during the COVID-19 pandemic.

July 1, 2020

Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

September 11, 2019

Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.

July 10, 2019

Unintended patient safety risks due to wireless smart infusion pump library update delays.

March 13, 2019

Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment.

February 27, 2019

Pro/con debate: color-coded medication labels.

February 20, 2019

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

Intravenous smart pump drug library compliance: a descriptive study of 44 hospitals.

December 12, 2018

Challenges and opportunities for improving patient safety through human factors and systems engineering.

December 5, 2018

Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements.

October 17, 2018

Intravenous smart pumps: usability issues, intravenous medication administration error, and patient safety.

July 11, 2018

Strategies for optimizing OR drug safety.

April 4, 2018

Applying human-centered design thinking to enhance safety in the OR.

May 24, 2017

Inpatient Notes: human factors engineering and inpatient care—new ways to solve old problems.

April 26, 2017

See More About The Topic

Hospitals

Quality and Safety Professionals

Engineers

Medicine

Pharmacy

Quest for the ideal: a redesign of the medication use system.

COVID-19: Team and Human Factors to Improve Safety

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Quest for the ideal: a redesign of the medication use system.

COVID-19: Team and Human Factors to Improve Safety

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

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