A model for medication safety event detection.

Rita A. Snyder; Willa Fields

Commentary

A model for medication safety event detection.

April 28, 2010

Snyder RA, Fields W. Int J Qual Health Care. 2010;22(3):179-86.

View more articles from the same authors.

This AHRQ-funded work describes a model to identify medication safety events that applies a systems approach and provides an example case study to demonstrate its use.

Free full text

PubMed citation

Available at

Related Resources From the Same Author(s)

Reducing preventable medication safety events by recognizing renal risk.

May 14, 2008

Linking nurse characteristics, team member effectiveness, practice environment, and medication error incidence.

January 25, 2012

Reducing continuous intravenous medication errors in an intensive care unit.

September 23, 2015

Medication room madness: calming the chaos.

November 4, 2009

Reliability evaluation of the adapted National Coordinating Council Medication Error Reporting and Prevention (NCC MERP) index.

June 13, 2007

Why 'Universal Precautions' are needed for medication lists.

September 7, 2016

Limits on opioid prescribing leave patients with chronic pain vulnerable.

May 15, 2019

Addressing medicine's bias against patients who are overweight.

March 27, 2019

Design and implementation of the infection prevention program into risk management: managing high level disinfection and sterilization in the outpatient setting.

June 24, 2020

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

March 14, 2007

The Perruche case and the issue of compensation for the consequences of medical error.

October 19, 2005

Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care.

June 28, 2017

Getting it right for patient safety: specimen collection process improvement from operating room to pathology.

September 28, 2016

Healthcare-associated infections: a national patient safety problem and the coordinated response.

February 19, 2014

Association of nurse workload with missed nursing care in the neonatal intensive care unit.

November 21, 2018

A descriptive study of nurse-reported missed care in neonatal intensive care units.

May 6, 2015

Adverse drug events resulting from patient errors in older adults.

March 7, 2007

Patient misidentifications caused by errors in standard barcode technology.

September 1, 2010

How communication among members of the health care team affects maternal morbidity and mortality.

January 18, 2017

Safety standards: implementing fall prevention interventions and sustaining lower fall rates by promoting the culture of safety on an inpatient rehabilitation unit.

December 9, 2015

Error traps in acute pain management in children.

September 21, 2022

Success in hospital-acquired pressure ulcer prevention: a tale in two data sets.

December 12, 2018

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review.

November 10, 2010

Apology laws and malpractice liability: what have we learned?

July 8, 2020

Reducing accidental extubation in neonates.

March 5, 2008

Malpractice claims related to diagnostic errors in the hospital.

August 23, 2017

Physician perspectives on addressing anti-Black racism.

February 14, 2024

Building safer systems through critical occurrence reviews: nine years of learning.

November 10, 2010

Whistleblowing and patient safety: the patient's or the profession's interests at stake.

July 20, 2011

ED handoffs: observed practices and communication errors.

July 20, 2011

The problem with medication reconciliation.

August 31, 2016

Communicating doses of pediatric liquid medicines to parents/caregivers: a comparison of written dosing directions on prescriptions with labels applied by dispensed pharmacy.

May 21, 2014

An in-depth analysis of medication errors in hospitalized patients with HIV.

May 18, 2011

Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors.

March 23, 2016

The intersection of traumatic childbirth and obstetric racism: a qualitative study.

February 7, 2024

A nurse-driven system for improving patient quality outcomes.

April 12, 2006

Hidden curricula, ethics, and professionalism: clinical learning environments in becoming and being a physician: a position paper of the American College of Physicians.

February 28, 2018

Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.

October 26, 2016

Necessity for a pathway for "high-alert" patients.

May 23, 2018

Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care.

August 24, 2022

Incidence and prevention of iatrogenic urethral injuries.

May 7, 2008

Development and evaluation of a 1-day interclerkship program for medical students on medical errors and patient safety.

January 31, 2007

Physician impairment and rehabilitation: reintegration into medical practice while ensuring patient safety: a position paper from the American College of Physicians.

June 19, 2019

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

November 30, 2016

Patients' perception of types of errors in palliative care—results from a qualitative interview study.

September 7, 2016

Reporting of death in US Food and Drug Administration medical device adverse event reports in categories other than death.

August 11, 2021

Economic analysis of the prevalence and clinical and economic burden of medication error in England.

July 1, 2020

Just-in-time training for high-risk low-volume therapies: an approach to ensure patient safety.

July 8, 2015

Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study.

April 9, 2014

The impact of dedicated medication nurses on the medication administration error rate: a randomized controlled trial.

March 27, 2005

Physician perspectives on responding to clinician-perpetuated interpersonal racism against Black patients with serious illness.

September 13, 2023

Advanced practice nursing students' identification of patient safety issues in ambulatory care.

April 10, 2013

Hospitalizations and deaths related to adverse drug events worldwide: systematic review of studies with national coverage.

May 25, 2022

The delivery of safe and effective test result communication, management and follow-up.

September 27, 2023

Diagnostic errors reported in primary healthcare and emergency departments: a retrospective and descriptive cohort study of 4830 reported cases of preventable harm in Sweden.

October 9, 2019

A mixed-methods systematic review of interventions to address incivility in nursing.

July 15, 2020

March 11, 2020

Every error a treasure: improving medication use with a nonpunitive reporting system.

July 18, 2007

Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety.

September 9, 2009

Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency.

July 22, 2009

Development of a self-report instrument to measure patient safety attitudes, skills, and knowledge.

February 11, 2009

Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders.

November 7, 2007

Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: a randomised controlled trial.

November 8, 2017

Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes.

May 25, 2016

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

October 13, 2010

The Henry Ford Production System: reduction of surgical pathology in-process misidentification defects by bar code-specified work process standardization.

May 27, 2009

The costs associated with adverse drug events among older adults in the ambulatory setting.

December 7, 2005

The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review.

April 16, 2008

Patient safety issues in advanced practice nursing students' care settings.

November 9, 2011

Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications.

March 18, 2009

Evaluating the effect of data standardization and validation on patient matching accuracy.

April 10, 2019

Measurement of ambulatory medication errors in children: a scoping review.

December 13, 2023

Prescribers' responses to alerts during medication ordering in the long term care setting.

August 30, 2006

Perspectives about racism and patient-clinician communication among black adults with serious illness.

July 26, 2023

Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting.

August 11, 2010

Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care.

January 18, 2006

Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care.

October 26, 2005

The safety of warfarin therapy in the nursing home setting.

June 13, 2007

Medication errors recovered by emergency department pharmacists.

July 14, 2010

Dementia and risk of adverse warfarin-related events in the nursing home setting.

November 21, 2012

Adverse events in long-term care residents transitioning from hospital back to nursing home.

August 7, 2019

The association of nursing home characteristics and quality with adverse events after a hospitalization.

April 28, 2021

Using the ISMP Medication Safety Self-Assessment to improve medication use processes.

March 6, 2005

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

February 23, 2011

Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets.

August 30, 2017

The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives.

February 7, 2007

An exploration of safety climate in nursing homes.

August 8, 2012

Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

March 6, 2005

Strategies for detecting adverse drug events among older persons in the ambulatory setting.

March 6, 2005

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study.

August 22, 2012

Human factors–focused reporting system for improving care quality and safety in hospital wards.

May 2, 2012

Documenting the indication for antimicrobial prescribing: a scoping review.

November 2, 2022

Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications.

November 13, 2013

Talking with patients about other clinicians' errors.

November 6, 2013

The incidence of adverse drug events in two large academic long-term care facilities.

April 15, 2005

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

A randomized trial of nighttime physician staffing in an intensive care unit.

June 5, 2013

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

February 11, 2009

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.

March 27, 2013

Reevaluation of diagnosis in adults with physician-diagnosed asthma.

February 1, 2017

Related Resources

Network of Patient Safety Databases Chartbook.

November 8, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

Inpatient patient safety events in vulnerable populations: a retrospective cohort study.

November 18, 2020

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

November 4, 2020

Review of medication errors that are new or likely to occur more frequently with electronic medication management systems.

July 17, 2019

Implementing safety hotlines: Stamford Health's experience and future opportunities.

September 19, 2018

Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge.

December 17, 2014

A medication-based trigger tool to identify adverse events in pediatric anesthesiology.

July 2, 2014

Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.

May 14, 2014

Adverse drug events in surgical patients: an observational multicentre study.

November 6, 2013

Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients.

September 25, 2013

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

June 12, 2013

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

January 30, 2013

Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.

October 10, 2012

Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients.

August 1, 2012

Automated identification of extreme-risk events in clinical incident reports.

February 8, 2012

Patient safety event reporting in a large radiology department.

September 21, 2011

Medicines reconciliation using a shared electronic health care record.

September 14, 2011

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

August 24, 2011

The pros and cons of electronic prescribing for children.

July 27, 2011

A systemic methodology for risk management in healthcare sector.

June 29, 2011

From research to practice: factors affecting implementation of prospective targeted injury-detection systems.

June 8, 2011

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

June 8, 2011

Patient-assisted incident reporting: including the patient in patient safety.

June 1, 2011

Effect of admission medication reconciliation on adverse drug events from admission medication changes.

May 25, 2011

See More About The Topic

General Hospitals

Risk Managers

Quality and Safety Professionals

Hospital Pharmacy

Medication Errors/Preventable Adverse Drug Events

A model for medication safety event detection.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

A model for medication safety event detection.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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