Unsafe medication systems in hospitals can lead to adverse drug events (ADEs). This review discusses patient care and organizational factors that contribute to ADEs, methods to detect medication errors, and prevention strategies such as medication reconciliation and enhanced pharmacist participation.

… a national surveillance system for malpractice claims. … Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res . … … BL … TB … NM … KM … DK … YJ … DM … Y. … PI … TH … SK … JS … MS … MD … MB … J. … W. … JW … KK … K. … R. … JH … M. … …

Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.

This report evaluates the implementation of a quality improvement initiative designed to characterize, track, and mitigate adverse events related to health information technology (IT). Investigators sought to determine challenges to engaging in identifying and addressing safety risks related to health IT in 11 health care organizations, and this publication outlines experiences and lessons learned from participating institutions. The authors call for greater awareness of safety risks related to health IT, better cooperation between risk management and health IT departments, identification of safety measures for health IT, incentives for health IT developers and vendors to improve health IT safety, and increased investment in risk management, health IT, and safety in ambulatory settings. The recommendations in this report serve as a blueprint for future practice and policy efforts to augment safety in the era of electronic health records.

… and implementation of patient engagement strategies. … Schneider EC, ed. Int J Qual Healthc . 2014;26(suppl 1):1-115. … DUQuE Project Consortium … EC … D. … NS … O. … H. … R. … A. … OA … M. … C. … R. … CA … …

… … DA … HH … KL … L. … K. … K. … R. … RR … D. … P. … DP … KJ … EM … S. … L. … DA … Battles … Farr … Cataife … Weinberg … … Sinkowitz-Cochran … Jeeva … Wright … Mendel … Baker … Leuschner … Gall … Siegel … Hiatt … Pegues … JB Battles … SL … … RR Jeeva … D. Wright … P. Mendel … DP Baker … KJ Leuschner … EM Gall … S. Siegel … L. Hiatt … DA Pegues …

This white paper details how health care organizations can identify health information technology concerns and improve systems to reduce risks.

Articles in this special issue explore theory-driven and simulation-based approaches to improve teamwork in health care.

This book discusses evidence, tools, and case examples to help prepare organizations for problems associated with implementation and use of electronic health records.

… trends in patient safety improvement. … Farley DO, Ridgely MS, Mendel P, et al. Santa Monica, CA: RAND … … P. … SS … CL … R. … MD … AM … P. … JW … H. … JA … C. … JS … Farley … Ridgely … Mendel … Teleki … Damberg … Shaw … …

This supplement consists of 12 articles drawn from a 2008 conference on diagnostic error, covering topics such as medical problem solving, clinical decision making, diagnostic decision support systems, and educational approaches to reducing diagnostic errors.

This special series of articles highlights the progress and current state of patient safety since the landmark IOM report. The series was developed by the Agency for Healthcare Research and Quality (AHRQ) as a method to critically evaluate their efforts, and those of their grantees, in funding more than 230 patient safety projects. The compilation showcases AHRQ's efforts to catalyze innovation and advance knowledge in patient safety, reflected in part by the articles in this series. An introductory editorial highlights themes that should drive the next 10 years of patient safety progress, which include changing safety culture, increasing transparency in providing care and examining risk, embracing the power of multidisciplinary teams, realizing the benefits of information technology, and approaching every issue through the patient's eyes.

This report discusses Agency for Healthcare Research and Quality's (AHRQ) involvement in patient safety activities between 2004-2005 and provides suggestions for future actions. This document is the third of four yearly publications funded by AHRQ to assess their work.

This report analyzes AHRQ's patient safety activities, synthesizes results of the full RAND evaluation, and discusses the knowledge generated by funded research projects as well as how these have contributed to improvement.

This monograph reports on the concept of creating a unique patient identifier system and addresses potential privacy, error, and cost issues.

This AHRQ-sponsored special issue includes a collection of studies and commentaries that discuss health information technology and its potential to improve medical care.

… … D. … J. … S. … S. … C. … P. … M. … GI … EA … Y. … S. … MS … JJ … LS … M. … AH … MK … J. … J. … E. … Paul … Carmona … … Fesko … Lenahan … Gadon … Balch … Jacobs … Partida … Wu … Ridgely … Escarce … Morales … Regenstein … Chen … Youdelman … … … M. Gadon … GI Balch … EA Jacobs … Y. Partida … S. Wu … MS Ridgely … JJ Escarce … LS Morales … M. Regenstein … AH …

… Santa Monica, CA: Rand Corporation; 2007. … DO … SC … CL … MS … A. … MD … ME … SS … P. … Farley … Morton … Damberg … Ridgely … Fremont … Greenberg … Sorbero … Teleki … Mendel … DO Farley … SC Morton … CL Damberg … MS Ridgely … A. Fremont … MD Greenberg … ME Sorbero … SS …

… … TW … EJ … TA … BJ … PG … D. … NT … M. … P. … SD … J. … SN … RW … B. … C. … S. … EJ … D. … S. … P. … A. … DM … DW … RI … M. … DD … DA … LJ … RA … BS … AW … JL … R. … Leape … Berwick … … … Adu … Richards … Peters … Barach … Small … Reason … Weingart … Gibberd … Harrison … Vincent … Taylor-Adams … …