Narrow Results Clear All
- WebM&M Cases 2
- Perspectives on Safety 1
- Commentary 14
- Review 3
- Study 26
- Audiovisual 6
- Book/Report 7
- Newspaper/Magazine Article 22
- Toolkit 2
- Web Resource 9
- Meeting/Conference 3
- Press Release/Announcement 3
- Communication Improvement
- Culture of Safety 4
Education and Training
- Students 1
- Error Reporting and Analysis 12
- Human Factors Engineering 19
- Legal and Policy Approaches 4
- Logistical Approaches 1
- Quality Improvement Strategies 17
- Research Directions 1
- Specialization of Care 5
- Teamwork 1
- Clinical Information Systems 6
- Transparency and Accountability 1
- Discontinuities, Gaps, and Hand-Off Problems 7
- Medication Errors/Preventable Adverse Drug Events 46
- Family Members and Caregivers 1
- Health Care Executives and Administrators 34
Health Care Providers
- Nurses 4
- Pharmacists 37
- Physicians 14
- Non-Health Care Professionals 10
- Patients 35
- Asia 1
- Australia and New Zealand 3
- Europe 3
- Canada 2
Search results for ""
Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Cases & Commentaries
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Perspectives on Safety > Perspective
with commentary by Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
Journal Article > Study
Stewart D, Helms P, McCaig D, Bond C, McLay J. Br J Clin Pharmacol. 2005;59:677-683.
The investigators issued questionnaires to parents in seven community pharmacies to prospectively monitor pediatric adverse drug reactions (ADRs). They found that the system was effective for reporting ADRs.
FDA Public Health Advisory. Silver Spring, MD: US Food and Drug Administration; December 21, 2007.
This Food and Drug Administration public health advisory alerts health care professionals, patients, and their caregivers to the possibility for overdoses of fentanyl in patients using fentanyl skin patches for pain control.
ISMP Medication Safety Alert! Acute Care Edition. June 30, 2005;10.
This alert cautions against the use of automated medication-refill kiosks.
Chase M. Wall Street Journal. August 16, 2005:D1.
This article reports that in other countries, some medications have the same brand name as U.S. medications but contain completely different ingredients, often for treatment of different conditions. To avoid mix-ups, the article cautions against purchasing prescription medications abroad.
Tools/Toolkit > Multi-use Website
National Council on Patient Information and Education.
This Web site provides information and tools that support an educational campaign to encourage high-quality communication about medication use. The annual observance is in October and the 2018 theme is "Taking Action to Prevent Opioid Abuse and Misuse".
Franklin D. New York Times. October 25, 2005:F1.
This article discusses an important health literacy and medication safety concern: the absence of standardization of colored warning labels applied to prescription bottles. Inconsistent messages, icons, and colors may cause confusion for consumers.
ISMP Medication Safety Alert! Acute Care Edition. November 17, 2005;10:1-3.
This article discusses how community pharmacies are contributing to patient safety and suggests that mail service and community pharmacies work together to provide the safest care possible.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; September 2010. AHRQ Publication No. 10-M052-C.
This 5-point checklist provides consumers with steps to help ensure the safety of their medication use.
Rockville, MD: Agency for Healthcare Research and Quality; December 2005.
This consumer video provides content complementary to the Agency for Healthcare Research and Quality checklist Check Your Medicines: Tips for Taking Medicines Safely.
Consumers Filling U.S. Prescriptions Abroad May Get the Wrong Active Ingredient Because of Confusing Drug Names.
FDA Public Health Advisory [US Food and Drug Administration Web site]. January 2006.
This U.S. Food and Drug Administration advisory alerts clinicians and consumers to potential mistakes in prescriptions purchased abroad. The advisory includes a table of medications known to contain different active ingredients when purchased outside the United States.
Journal Article > Study
Sharif I, Lo S, Ozuah PO. J Health Care Poor Underserved. 2006;17:65-69.
The authors surveyed pharmacies in the Bronx, New York, and found that 69% could provide prescription labels in Spanish, and that most used a computer program to translate the labels.
Perry LE. Drug Topics: Health-System Edition. March 20, 2006.
This article reports on the Joint Commission's focus on medication reconciliation and illustrates how health care organizations are applying the process to prevent medication errors.
Journal Article > Review
Warner A, Menachemi N, Brooks RG. Hosp Pharm. 2006;41:542-551.
This literature review examined the assumption that low levels of health literacy contribute to medical errors. The authors summarize the findings from past studies that addressed health literacy in relationship to medication errors and health outcomes before drawing several conclusions. They report that studies do associate low literacy levels with adverse health outcomes, but further investigation is required to better understand the link between literacy and medication errors. A past report from the Institute of Medicine examined the field of health literacy broadly and discussed strategies to drive improvement efforts.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Journal Article > Study
Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research.
Brown M, Frost R, Ko Y, Woosley R. Patient Educ Couns. 2006;62:302-315.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
Foreman J. Los Angeles Times. September 4, 2006:F3.
This article describes what patients can do to minimize opportunities for medication error.