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1 - 15 of 15
Drug Shortage Task Force. Silver Spring, MD: US Food and Drug Administration; 2020.
Drug shortages result from a variety of systemic failures. This report identifies market demands and financial factors that disrupt medication production. The materials recommend development of shared mental models on the causes of medication shortages and how they affect patients. Legislative and pharmaceutical industry-level quality improvement strategies designed to address systemic weaknesses are reviewed.
Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
Following the implementation of a large clinical information communication technology project, this report identified interoperability and usability failures and noted medication ordering and management as particularly vulnerable to errors.
London, UK: Care Quality Commission; October 2009. CQC-039-500-ESP-102009. ISBN: 9781845622442.
This report analyzed how medication information is shared among UK practices and patients after a hospital stay and found that 81% of general practices thought that patient information given to them from hospitals was incomplete or inaccurate.
Reynard J, Reynolds J, Stevenson P. Oxford, UK: Oxford University Press; 2009. ISBN: 9780199239931.
This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.
Adlassnig KP, Blobel B, Mantas J, Masic I, eds. Stud Health Technol Inform. 2009;150:497-566. In: Medical Informatics in a United and Healthy Europe. Washington, DC: IOS Press. ISBN: 9781607500445.
Part of a comprehensive electronic compilation on medical informatics, this series of papers examines topics surrounding the use of health information technology (HIT) to detect, report, and learn from adverse events.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.
Oakbrook Terrace, IL: The Joint Commission; November 2008.
The quality of care delivered at US hospitals continues to improve, according to data gathered by the Joint Commission from nearly 1,500 institutions. Hospitals improved their provision of evidence-based care for patients with heart attacks, congestive heart failure, and pneumonia, and also improved at prevention of health care–associated infections in surgical patients. As in the 2007 report, adherence to the National Patient Safety Goals was more mixed. Although performance improved in some areas (including medication reconciliation and eliminating "do not use" abbreviations), many hospitals do not systematically perform time outs prior to procedures, or have reliable mechanisms for communicating critical test results.
The Healthcare Commission. London, UK: The Stationary Office; 2008.
This report shares findings from a 5-year analysis of the state of health care in the United Kingdom. It reveals that while awareness of patient safety has improved since the first report in the series, the UK health system needs to be more consistent in its application of patient-centeredness concepts to fully promote quality.
Washington, DC: Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services; 2007.
This report provides two example scenarios—inpatient medication reconciliation and medication management in ambulatory care—to explore how improved information exchange can support safe medication management.
American Society of Health-System Pharmacists, Joint Commission on Accreditation of Healthcare Organizations. Oakbrook Terrace IL; Joint Commission Resources: 2009. ISBN 9781599403090.
This book provides background on the medication reconciliation process and tips for its application, along with sample forms, checklists, and case studies.
Dublin: Irish Society for Quality and Safety in Healthcare; 2004.
This report provides results from a 26-hospital survey investigating areas of service and care weakness in Irish hospitals. The research revealed problems related to information transfer, overwork, and lack of patient involvement in decision making about their care.