Supporting the Patient Safety and Clinical Pharmacy Services Collaborative.

Jimmy R. Mitchell

Commentary

Supporting the Patient Safety and Clinical Pharmacy Services Collaborative.

July 25, 2012

Mitchell JR. Am J Health Syst Pharm. 2012;69(14):1246-50.

View more articles from the same authors.

This piece, originally delivered as a lecture, discusses a community-level collaborative to improve medication safety in patients with chronic illnesses.

PubMed citation

Available at

Related Resources From the Same Author(s)

Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure.

February 8, 2023

Targeted chart review of pediatric patient safety events identified by the Agency for Healthcare Research and Quality's Patient Safety Indicators methodology.

January 3, 2007

'Not another safety culture survey': using the Canadian patient safety climate survey (Can-PSCS) to measure provider perceptions of PSC across health settings.

November 13, 2013

The lost art of doctoring: reflections of a pediatric resident.

November 15, 2017

Is your code cart ready?

September 28, 2005

A web application to involve patients in the medication reconciliation process: a user-centered usability and usefulness study.

December 19, 2018

Has the COVID pandemic strengthened or weakened health care teams? A field guide to healthy workforce best practices.

March 31, 2021

Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized trial.

July 26, 2017

Resident fatigue: is there a patient safety issue?

January 6, 2010

From box ticking to the black box: the evolution of operating room safety.

September 4, 2019

How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups.

July 1, 2006

Enabling sustained communication with patients for safe and effective management of oral chemotherapy: a longitudinal ethnography.

March 17, 2021

Designing a critical care nurse–led rapid response team using only available resources: 6 years later.

July 9, 2014

Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis.

May 10, 2006

1,300 days and counting: a risk model approach to preventing retained foreign objects (RFOs).

May 23, 2018

Patient safety and the question of dignitary harms.

March 15, 2023

Deferral of care for serious non-COVID-19 conditions: a hidden harm of COVID-19.

November 18, 2020

Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital.

March 16, 2016

Use of a human factors classification framework to identify causal factors for medication and medical device-related adverse clinical incidents.

October 21, 2015

Side errors in neurosurgery.

November 15, 2006

Improving the quality and safety of patient care in cardiac anesthesia.

December 10, 2014

A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients.

May 12, 2010

Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors.

November 10, 2021

Using data to enhance performance and improve quality and safety in surgery.

August 30, 2017

An innovative collaborative model of care for undiagnosed complex medical conditions.

May 31, 2017

Enhancing patient safety: a national standard for cyber resiliency in healthcare.

September 20, 2023

Mobilising or standing still? A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016.

June 21, 2017

The "physician-led chart audit": engaging providers in fortifying a culture of safety.

March 19, 2014

Critical incident stress management (CISM) in complex systems: cultural adaptation and safety impacts in healthcare.

October 1, 2014

Retrieval of iatrogenic intravascular foreign bodies.

December 5, 2012

Hope modified the association between distress and incidence of self-perceived medical errors among practicing physicians: prospective cohort study.

May 30, 2012

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

Using an advanced practice nursing model for a rapid response team.

December 3, 2008

Effects of weekend admission and hospital teaching status on in-hospital mortality.

March 6, 2005

Failure events in transition of care for surgical patients.

March 5, 2014

Patient safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human.'

August 12, 2015

Why do interns make prescribing errors? A qualitative study.

February 13, 2008

Impact of a standard medication chart on prescribing errors: a before-and-after audit.

December 16, 2009

Patient perceptions of mistakes in ambulatory care.

September 22, 2010

Minimizing inappropriate medications in older populations: a ten-step conceptual framework.

April 4, 2012

The Daily Plan: including patients for safety's sake.

April 11, 2012

Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit and general ward.

August 1, 2018

Augmenting health care failure modes and effects analysis with simulation.

March 5, 2014

Predicting future staffing needs at teaching hospitals: use of an analytical program with multiple variables.

April 25, 2007

Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia?

February 3, 2010

Good people who try their best can have problems: recognition of human factors and how to minimise error.

January 27, 2016

Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention.

September 21, 2022

Hospital staffing and health care–associated infections: a systematic review of the literature.

October 3, 2018

Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study.

May 17, 2017

Clinical dilemmas and a review of strategies to manage drug shortages.

May 15, 2013

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors.

December 19, 2007

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.

April 4, 2007

Leading article: how can I optimise my role as a leader within the surgical team?

August 31, 2016

Relevance of the Agency for Healthcare Research and Quality Patient Safety Indicators for children's hospitals.

March 6, 2005

Distractions in the operating room: a survey of the healthcare team.

April 5, 2023

Potentially inappropriate prescribing in older patients discharged from acute care hospitals to residential aged care facilities.

October 29, 2014

Assessing adverse events among home care clients in three Canadian provinces using chart review.

November 27, 2013

Improving medication administration safety in solid organ transplant patients through barcode-assisted medication administration.

August 14, 2013

A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.

February 2, 2022

The cost of opioid–related adverse drug events.

October 8, 2014

A 'paperless' wall-mounted surgical safety checklist with migrated leadership can improve compliance and team engagement.

January 27, 2016

Medically-necessary, time-sensitive procedures: a scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic.

May 6, 2020

Patient safety: a consumer's perspective.

April 27, 2011

Medical errors in neurosurgery.

December 3, 2014

Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits.

July 10, 2017

A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist.

October 30, 2013

Opioid prescribing after childbirth and risk for serious opioid-related events: a cohort study.

July 1, 2020

Detectability of medication errors with a STOPP/START-based medication review in older people prior to a potentially preventable drug-related hospital admission.

December 21, 2022

Automated capture of intraoperative adverse events using artificial intelligence: a systematic review and meta-analysis.

March 15, 2023

Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns.

March 14, 2018

Changing operating room culture: implementation of a postoperative debrief and improved safety culture.

February 14, 2018

Hospital admissions due to adverse drug reactions: a report from the Boston Collaborative Drug Surveillance Program.

March 27, 2005

Body of evidence: do autopsy findings impact medical malpractice claim outcomes?

April 29, 2020

Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study.

May 22, 2013

SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations.

March 14, 2012

Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths

October 2, 2019

ASHP guidelines on the safe use of automated dispensing devices.

August 29, 2021

A human factors curriculum for surgical clerkship students.

January 5, 2011

Seniors managing multiple medications: using mixed methods to view the home care safety lens.

March 2, 2016

Pediatric medication safety considerations for pharmacists in an adult hospital setting.

November 6, 2019

Overuse of medical imaging and its radiation exposure: who’s minding our children?

September 28, 2016

The cost of harm and savings through safety: using simulated patients for leadership decision support.

September 12, 2012

No simple fix for fixation errors: cognitive processes and their clinical applications.

January 13, 2010

Impact of duty hour limits on resident training in otolaryngology.

June 15, 2005

Liability reform should make patients safer: "Avoidable classes of events" are a key improvement.

October 19, 2005

Changes in the diagnostic process during 40 years of clinicopathologic conferences.

March 27, 2005

The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality.

March 27, 2005

Preventable deaths: who, how often, and why?

March 27, 2005

The role of the informal and formal organisation in voice about concerns in healthcare: a qualitative interview study.

June 16, 2021

Do hospital boards matter for better, safer, patient care?

March 8, 2017

The Team Climate Inventory: application in hospital teams and methodological considerations.

August 27, 2008

A national survey of safe practice with epidural analgesia in obstetric units.

May 7, 2008

What counts as a voiceable concern in decisions about speaking out in hospitals: a qualitative study.

January 19, 2022

Adverse events and near miss reporting in the NHS.

August 24, 2005

Real time patient safety audits: improving safety every day.

August 17, 2005

Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views.

August 24, 2005

Understanding the clinical implications of resident involvement in uncommon operations.

May 1, 2019

Reduction in hospital mortality over time in a hospital without a pediatric medical emergency team: limitations of before-and-after study designs.

May 11, 2011

Adverse drug event trigger tool: a practical methodology for measuring medication related harm.

March 6, 2005

Spike in fatal medication errors at the beginning of each month.

March 6, 2005

Related Resources

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views.

November 29, 2023

Reduced postdischarge incidents after implementation of a hospital-to-home transition intervention for children with medical complexity.

October 4, 2023

Smart Healthcare Safety.

October 4, 2023

Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023.

October 4, 2023

Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment.

July 12, 2023

Maximizing student potential: lessons for pharmacy programs from the patient safety movement.

May 17, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Making polypharmacy safer for children with medical complexity.

April 5, 2023

A health system that won't learn from its mistakes.

September 21, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscious bias within health systems.

November 17, 2021

Assessment of patient-preferred language to achieve goal-aligned deprescribing in older adults.

June 30, 2021

"Talk About Your Medicines" Month.

April 4, 2021

Patient Safety Innovations

Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health

June 12, 2020

Annual Perspective

Patient Safety in Primary Care

February 21, 2020

Medical abbreviations that have contradictory or ambiguous meanings.

February 12, 2020

Capturing patients' perspectives on medication safety: the development of a patient-centered medication safety framework.

May 8, 2019

Consumer-directed technologies to improve medication management and safety.

April 24, 2019

March 27, 2019

Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error.

March 6, 2019

Engineering a foundation for partnership to improve medication safety during care transitions.

February 6, 2019

A prescription for enhancing electronic prescribing safety.

December 12, 2018

Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice.

November 15, 2017

The power of regret.

October 25, 2017

Polypharmacy in the elderly--when good drugs lead to bad outcomes: a teachable moment.

May 3, 2017

Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention.

April 12, 2017

Lost in translation: medication labeling for immigrant families.

December 21, 2016

Preventing diagnostic errors in primary care.

October 12, 2016

Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study.

October 5, 2016

"Use as directed" can cause confusion for both patients and practitioners.

September 14, 2016

See More About The Topic

Hospitals

Ambulatory Care

Health Care Providers

Pharmacy

Medication Safety

Supporting the Patient Safety and Clinical Pharmacy Services Collaborative.

Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Supporting the Patient Safety and Clinical Pharmacy Services Collaborative.

Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health

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