Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications.

L. V Graudins; C. Ingram; B. T Smith; W. J Ewing; M. Vandevreede

Study

Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications.

March 4, 2015

Graudins LV, Ingram C, Smith BT, et al. International Journal for Quality in Health Care. 2014;27(1).

View more articles from the same authors.

Omitted or delayed dosing of medications is an aspect of missed nursing care in inpatient settings. This quality improvement study describes an audit and feedback tool to ensure timely medication administration in hospitals. This type of standardized work and feedback, influenced by human factors engineering, has been applied to many patient safety programs.

Free full text

PubMed citation

Related Resources From the Same Author(s)

Measuring patient safety climate: a review of surveys.

October 12, 2005

Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability.

November 22, 2006

Time of day effects on the incidence of anesthetic adverse events.

August 23, 2006

The effect of cognitive debiasing training among family medicine residents.

July 1, 2015

Long-term reduction in adverse drug events: an evidence-based improvement model.

July 18, 2012

A 3-year study of medication incidents in an acute general hospital.

April 23, 2008

Responding to patient safety incidents: the "seven pillars."

April 7, 2010

Examination of maternal near-miss experiences in the hospital setting among Black women in the United States.

December 14, 2022

Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program.

May 15, 2013

An alternative strategy for studying adverse events in medical care.

March 27, 2005

Do faculty and resident physicians discuss their medical errors?

October 15, 2008

Challenging hierarchy in healthcare teams--ways to flatten gradients to improve teamwork and patient care.

April 19, 2017

Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.

February 3, 2016

Physician knowledge, attitudes, and behavior related to reporting adverse drug events.

March 27, 2005

Errors during the preparation of drug infusions: a randomized controlled trial.

August 22, 2012

Crisis management during anaesthesia: the development of an anaesthetic crisis management manual.

June 22, 2005

Using simulation to address hierarchy issues during medical crises.

February 13, 2013

Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room.

July 2, 2008

Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting.

May 31, 2006

Eliminating perioperative adverse events at Ascension Health.

May 9, 2007

Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation.

February 17, 2021

Errors, incidents and accidents in anaesthetic practice.

March 6, 2005

Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions.

March 10, 2010

The "Seven Pillars" response to patient safety incidents: effects on medical liability processes and outcomes.

September 7, 2016

Relationship between tort claims and patient incident reports in the Veterans Health Administration.

April 21, 2005

Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior.

October 12, 2005

Thinking ethically about medical mistakes.

March 13, 2013

Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions.

June 8, 2011

Sources of nurse-sensitive inpatient safety improvement.

December 21, 2022

Hospital quality-review spending and patient safety: a longitudinal analysis using instrumental variables.

July 7, 2021

Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system.

February 20, 2008

Development and evaluation of a checklist to support decision making in cancer multidisciplinary team meetings: MDT-QuIC.

January 25, 2012

Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network.

June 11, 2008

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008.

August 31, 2011

Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized controlled trial.

March 12, 2014

Innovative patient safety curriculum using iPad game (PASSED) improved patient safety concepts in undergraduate medical students.

September 21, 2016

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

January 30, 2005

We want to know: patient comfort speaking up about breakdowns in care and patient experience.

October 17, 2018

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety.

December 19, 2007

Developing and implementing new safe practices: voluntary adoption through statewide collaboratives.

August 16, 2006

Liability associated with obstetric anesthesia: a closed claims analysis.

January 21, 2009

Connected care: reducing errors through automated vital signs data upload.

September 23, 2009

An analysis of electronic health record–related patient safety concerns.

July 2, 2014

Durable improvements in efficiency, safety, and satisfaction in the operating room.

May 28, 2008

We Want to Know-a mixed methods evaluation of a comprehensive program designed to detect and address patient-reported breakdowns in care.

May 20, 2020

Disclosing harmful medical errors to patients: tackling three tough cases.

September 30, 2009

The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency.

September 1, 2012

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge.

May 4, 2011

Culture change at the source: a medical school tackles patient safety.

January 31, 2006

Evaluation of drug interaction software to identify alerts for transplant medications.

March 6, 2005

Development of medical checklists for improved quality of patient care.

January 9, 2008

Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery.

September 18, 2019

A classification system for incidents and accidents in the health-care system.

March 6, 2005

Origin and uses of primum non nocere—above all, do no harm!

May 4, 2005

Building safer systems by ecological design: using restoration science to develop a medication safety intervention.

April 12, 2006

Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.

September 21, 2005

Organizational perspectives of nurse executives in 15 hospitals on the impact and effectiveness of rapid response teams.

April 19, 2017

Use of in-situ simulation to investigate latent safety threats prior to opening a new emergency department.

August 19, 2015

Video capture of clinical care to enhance patient safety.

March 1, 2006

The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose.

February 14, 2018

Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study.

January 30, 2005

Prioritising the prevention of medication handling errors.

October 8, 2008

Effect of changes in hospital nursing resources on improvements in patient safety and quality of care: a panel study.

November 28, 2018

Health-care professionals' views about safety in maternity services: a qualitative study.

February 11, 2009

Speaking across the drapes: communication strategies of anesthesiologists and obstetricians during a simulated maternal crisis.

June 6, 2012

Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient.

February 2, 2022

Novel analysis of clinically relevant diagnostic errors in point-of-care devices.

October 19, 2011

Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology ward.

February 22, 2006

Effect of day of the week on short- and long-term mortality after emergency general surgery.

April 5, 2017

Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.

March 27, 2005

Relationship between patient complaints and surgical complications.

February 15, 2006

Injury and liability associated with monitored anesthesia care: a closed claims analysis.

February 15, 2006

Assessment of latent factors contributing to error: addressing surgical pathology error wisely.

November 16, 2011

Directed peer review in surgical pathology.

September 1, 2012

The effect of provider characteristics on the responses to medication-related decision support alerts.

July 15, 2015

Attitudes and barriers to incident reporting: a collaborative hospital study.

February 22, 2006

Measures of patient safety in developing and emerging countries: a review of the literature.

March 17, 2010

Information chaos in primary care: implications for physician performance and patient safety.

November 30, 2011

Intravenous chemotherapy compounding errors in a follow-up pan-Canadian observational study.

May 9, 2018

Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections.

July 11, 2012

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

February 26, 2014

Crises in clinical care: an approach to management.

June 22, 2005

How are medication errors defined? A systematic literature review of definitions and characteristics.

November 3, 2010

Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.

July 28, 2010

Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research.

February 6, 2013

Lessons learned from implementing a principled approach to resolution following patient harm.

January 9, 2019

Building a culture of safety in ophthalmology.

November 2, 2016

Design and implementation of a point-of-care computerized system for drug therapy in Stockholm metropolitan health region--bridging the gap between knowledge and practice.

August 29, 2007

Tips to reduce dangerous interruptions by healthcare staff.

February 6, 2013

Involving users in the design of a system for sharing lessons from adverse incidents in anaesthesia.

April 5, 2006

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

December 6, 2006

Effects of a team-based assessment and intervention on patient safety culture in general practice: an open randomised controlled trial.

January 8, 2014

A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures.

March 4, 2009

An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm.

April 13, 2016

National Patient Safety Foundation agenda for research and development in patient safety.

March 27, 2005

Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit.

December 16, 2009

Using computerized virtual cases to explore diagnostic error in practicing physicians.

February 13, 2019

Hospital admission medication reconciliation in medically complex children: an observational study.

April 21, 2010

Enhancing psychological safety in mental health services.

June 9, 2021

Failure to weigh patients in hospital: a medication safety risk.

September 12, 2007

Related Resources

Annual Perspective

Communication During Transitions of Care

March 27, 2024

Methods for studying medication safety following electronic health record implementation in acute care: a scoping review.

January 10, 2024

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

WebM&M Cases

Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital.

June 14, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

A systems analysis of work-related violence in hospitals: stakeholders, contributory factors, and leverage points.

February 22, 2023

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.

August 10, 2022

Nurses' harm prevention practices during admission of an older person to the hospital: a multi-method qualitative study.

August 10, 2022

Moving on after critical incidents in health care: a qualitative study of the perspectives and experiences of second victims

May 11, 2022

What is needed to sustain improvements in hospital practices post-COVID-19? A qualitative study of interprofessional dissonance in hospital infection prevention and control.

May 4, 2022

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit.

November 17, 2021

Implementation strategies in the context of medication reconciliation: a qualitative study.

July 14, 2021

Older patients' engagement in hospital medication safety behaviours.

June 16, 2021

Evaluation of the quality of 'do not use' medication abbreviation audits: a key enabler to successful implementation of audit and feedback.

March 24, 2021

Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting.

March 3, 2021

Nurses' perceptions of open disclosure processes in cancer care: a cross-sectional study.

December 16, 2020

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.

November 25, 2020

Predictors of nursing home nurses' willingness to report medication near-misses.

May 13, 2020

Making Healthcare Safer III.

March 18, 2020

Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center.

January 29, 2020

Improving the quality of insulin prescribing for people with diabetes being discharged from hospital

October 16, 2019

Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit.

August 14, 2019

Intentional rounding—an integrative literature review.

August 7, 2019

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

July 17, 2019

Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study.

June 12, 2019

Contribution of adverse events to death of hospitalised patients.

April 17, 2019

In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States.

March 13, 2019

Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review.

October 10, 2018

ISMP Survey on Drug Shortages.

September 13, 2017

Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences.

September 7, 2016

See More About The Topic

Hospitals

Health Care Executives and Administrators

Nurse Care

Hospital Pharmacy

Medication Safety

Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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