Uptake of quality-related event standards of practice by community pharmacies.

Todd A. Boyle; Andrea Bishop; Craig Overmars; Kaleigh MacMaster; Thomas Mahaffey; Bev Zwicker; Neil J. MacKinnon

Study

Uptake of quality-related event standards of practice by community pharmacies.

April 30, 2014

Boyle TA, Bishop A, Overmars C, et al. J Pharm Pract. 2015;28(5):442-9.

View more articles from the same authors.

This analysis of community pharmacy practices found that while most have reporting of medication errors and near misses in place, few establish improvement plans or apply systems approaches to address errors. This finding underscores the need to learn from events and implement changes to resolve safety issues.

PubMed citation

Available at

Related Resources From the Same Author(s)

September 19, 2012

Pharmacist work stress and learning from quality related events.

November 9, 2016

The role of safety culture in influencing provider perceptions of patient safety.

December 14, 2016

Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study.

April 11, 2012

Use of an electronic information system to identify adverse events resulting in an emergency department visit.

December 22, 2010

Patient involvement in patient safety: a qualitative study of nursing staff and patient perceptions.

August 13, 2014

Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.

November 21, 2018

February 25, 2015

Applying Lean methods to improve quality and safety in surgical sterile instrument processing.

March 13, 2013

October 16, 2013

Confirming delivery: understanding the role of the hospitalized patient in medication administration safety.

May 28, 2014

Reducing errors through discharge medication reconciliation by pharmacy services.

August 26, 2015

Smart pumps: implications for nurse leaders.

March 30, 2011

Evaluation of the frequency of dispensing electronically discontinued medications and associated outcomes.

August 15, 2018

A new safety event reporting system improves physician reporting in the surgical intensive care unit.

June 14, 2006

Rural nurses' safeguarding work: reembodying patient safety.

June 15, 2011

Drug calculation ability of qualified paramedics: a pilot study.

February 28, 2018

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

March 2, 2016

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2017.

October 31, 2018

ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2015.

September 14, 2016

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2014.

August 12, 2015

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2010.

June 6, 2012

ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2009.

June 13, 2012

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011.

May 9, 2012

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2016.

September 20, 2017

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013.

July 23, 2014

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008.

May 20, 2009

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2007.

June 4, 2008

Interrater agreement with a standard scheme for classifying medication errors.

January 24, 2007

Predictive combinations of monitor alarms preceding in-hospital code blue events.

January 9, 2013

The association between a prolonged stay in the emergency department and adverse events in older patients admitted to hospital: a retrospective cohort study.

February 16, 2011

Utility of an online medication-error-reporting system.

November 23, 2005

Interruptions in a level one trauma center: a case study.

July 4, 2007

Wireless technologies and patient safety in hospitals.

July 12, 2006

Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.

October 30, 2013

Errors in after-hours phone consultations: a simulation study.

March 5, 2014

ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2018.

August 21, 2019

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing-2019.

September 30, 2020

ASHP National Survey of Pharmacy Practice in Hospital Settings: clinical services and workforce-2021.

October 19, 2022

A study of the frequency and rationale for overriding allergy warnings in a computerized prescriber order entry system.

June 20, 2007

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

Clinical reasoning in the wild: premature closure during the COVID-19 pandemic.

August 19, 2020

"Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient safety.

September 1, 2010

Adoption of technology to improve medication safety: perspectives of pharmacy directors.

January 10, 2007

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

Usability study of two common defibrillators reveals hazards.

January 2, 2008

Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.

January 25, 2006

Effect of communication errors during calls to an antimicrobial stewardship program.

March 26, 2008

Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis.

August 7, 2013

Reasons for after-hours calls by hospital floor nurses to on-call physicians.

May 30, 2007

Emotional impact of patient safety incidents on family physicians and their office staff.

March 21, 2012

Leading your organization to high reliability.

April 22, 2009

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

May 2, 2012

Incidence and types of preventable adverse events in elderly patients: population based review of medical records.

March 27, 2005

Out-of-hospital medication errors among young children in the United States, 2002–2012.

October 29, 2014

Is computer-assisted telephone triage safe? A prospective surveillance study in walk-in patients with non-life-threatening medical conditions.

April 18, 2012

Disclosing errors and adverse events in the intensive care unit.

April 5, 2006

Safety incidents in family medicine.

September 28, 2011

Medication errors associated with transition from insulin pens to insulin vials.

March 8, 2017

Unconscious bias among health professionals: a scoping review.

September 27, 2023

Relationship between medication errors and adverse drug events.

March 6, 2005

Costly issues of an uncommunicative OR.

May 3, 2006

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.

March 17, 2010

Team-based care: the changing face of cardiothoracic surgery.

October 11, 2017

Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review.

March 25, 2020

Patients use an internet technology to report when things go wrong.

June 20, 2007

Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals.

December 17, 2008

An exploratory study of knowledge brokering in hospital settings: facilitating knowledge sharing and learning for patient safety?

January 29, 2014

Communication patterns during routine patient care in a pediatric intensive care unit: the behavioral impact of in situ simulation.

May 11, 2022

The many faces of error disclosure: a common set of elements and a definition.

April 4, 2007

Review of patient safety incidents submitted from critical care units in England & Wales to the UK National Patient Safety Agency.

December 2, 2009

Bending the patient safety curve: how much can AI help?

February 1, 2023

Understanding diagnostic errors in medicine: a lesson from aviation.

June 21, 2006

Spreading a medication administration intervention organizationwide in six hospitals.

February 15, 2012

Strategic work-arounds to accommodate new technology: the case of smart pumps in hospital care.

June 27, 2007

Do patient safety indicators explain increased weekend mortality?

September 2, 2015

Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection.

January 31, 2006

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

April 4, 2007

Organizational learning and patient safety: hospital pharmacy settings.

November 6, 2019

Attending work hour restrictions: is it time?

January 28, 2009

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.

November 25, 2009

Operational measurement of diagnostic safety: state of the science.

October 7, 2020

Teamwork behaviours and errors during neonatal resuscitation.

March 24, 2010

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

June 3, 2015

Awareness and use of a cognitive aid for anesthesiology.

September 19, 2007

Accidental deaths, saved lives, and improved quality.

October 5, 2005

Validation of the Primary Care Patient Measure of Safety (PC PMOS) questionnaire.

May 1, 2019

The costs of developing, implementing, and operating a safety learning system in community practice.

December 11, 2013

The pros and cons of electronic prescribing for children.

July 27, 2011

Tracking intraoperative complications.

November 28, 2012

Does applying technology throughout the medication use process improve patient safety with antineoplastics?

February 5, 2014

Opioids, iatrogenic harm and disclosure of medical error.

April 7, 2010

Evidence and efficacy: time to think beyond the traditional randomised controlled trial in patient safety studies.

April 24, 2019

Adverse event protocol for interventional pain medicine: the importance of an organized response.

July 16, 2008

The iatrogenic-harm cost equation and new technology.

September 7, 2005

Safety skills for clinicians: an essential component of patient safety.

August 20, 2008

Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.

August 31, 2011

Disclosing adverse events to patients: international norms and trends.

April 30, 2014

Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications.

April 29, 2015

Patient safety event reporting in critical care: a study of three intensive care units.

March 21, 2007

Related Resources

California pharmacies are making millions of mistakes. They’re fighting to keep that secret.

September 20, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

ISMP Targeted Medication Safety Best Practices for Community Pharmacy.

April 19, 2023

Community Pharmacy Survey on Patient Safety Culture.

October 24, 2022

The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital in patients with polypharmacy.

April 27, 2022

Disrespectful behavior in your workplace.

April 13, 2022

Medication safety issues with newly authorized PAXLOVID.

January 12, 2022

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

October 20, 2021

WebM&M Cases

Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.

July 28, 2021

The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study.

July 28, 2021

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study.

May 5, 2021

Dispensing Errors.

December 16, 2020

Pharmacist counseling when dispensing naloxone by standing order: a secret shopper study of 4 chain pharmacies.

December 9, 2020

Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims.

November 4, 2020

WebM&M Cases

Multiple Levels Involved in Prescribing the Wrong Medication

September 30, 2020

Fighting against COVID-19: innovative strategies for clinical pharmacists.

May 6, 2020

Pharmacist linkage in care transitions: from academic medical center to community.

October 30, 2019

Community pharmacy medication review, death and re-admission after hospital discharge: a propensity score-matched cohort study.

September 4, 2019

Ten ways to improve medication safety in community pharmacies.

August 7, 2019

Effect of a central call center on employee perceptions of safety culture within community pharmacies in an academic health system.

June 5, 2019

Patient Safety.

May 22, 2019

Medication errors in community pharmacies: the need for commitment, transparency, and research.

February 20, 2019

Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies.

February 6, 2019

In patient safety efforts, pharmacists gain new prominence.

January 23, 2019

Analysis of medication therapy discontinuation orders in new electronic prescriptions and opportunities for implementing CancelRx.

November 14, 2018

Perspective

Safety in the Retail Pharmacy

October 1, 2018

Interview

In Conversation With… Michael Cohen, RPh, MS, ScD (hon)

October 1, 2018

Understanding procedural violations using Safety-I and Safety-II: the case of community pharmacies.

August 22, 2018

Evaluation of the frequency of dispensing electronically discontinued medications and associated outcomes.

August 15, 2018

Evaluation of patient safety culture in community pharmacies.

February 7, 2018

See More About The Topic

Outpatient Pharmacy

Pharmacists

Quality and Safety Professionals

Community Pharmacy

Medication Errors/Preventable Adverse Drug Events

Uptake of quality-related event standards of practice by community pharmacies.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Uptake of quality-related event standards of practice by community pharmacies.

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