Polypharmacy and medication overuse are known contributors to patient harm. This report outlines recommendations for combating medication overload. The recommendations include prescription review, issue awareness, point-of-care information access, training and industry influence reduction as tactics for improvement.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.

Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care admissions, emergency department use, ambulatory adverse events, and elderly patients affected by medication-related problems. Pharmacists are emphasized as pivotal to medication safety improvement efforts.

Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.

Errors in the prescription, preparation, and administration of medications hinder safe patient care. This book summarizes theories and international practices to provide clinical pharmacists with strategies to address barriers to medication safety.

This report provides preliminary outcome data from a six-cohort collaborative that used the comprehensive unit-based safety program and associated tools to prevent catheter-associated urinary tract infections (CAUTI). The early data show a decrease in the overall rate of CAUTI, with a more striking decrease in non-intensive care unit settings than in ICU settings.

This publication reports the impact hospital participation in CUSP had on patients. This AHRQ-funded program was designed to reduce central line infections using concepts tested in the successful Keystone program.

This manual offers practical advice on how to plan for and implement care team rounds that involve a variety of health care providers.

This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.

This book discusses the rise of the hospitalist movement within the context of quality and safety and reviews how hospitalists can support several National Patient Safety Goals.

This report describes how medication reconciliation and pharmacist counseling can help improve outcomes through greater patient adherence to medication regimens.

This report shares findings from analysis of more than 11,000 perioperative medication errors reported through Medmarx and includes recommendations to avoid these types of errors.

This report illustrates weaknesses in current pathology practice of breast cancer diagnosis and suggests improvements for reliability and effectiveness.