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- Communication Improvement 3
- Culture of Safety 1
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- Error Reporting and Analysis 2
- Quality Improvement Strategies
- Specialization of Care 1
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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.
Journal Article > Study
Kralewski JE, Dowd BE, Heaton A, Kaissi A. Med Care. 2005;43:817-825.
The study, which analyzed prescription drug error claims for 78 group practices, found both direct and indirect relationships between culture, practice structure, and medication errors. The authors believe that better care coordination can improve medication safety in the outpatient environment.
Journal Article > Study
Using human error theory to explore the supply of non-prescription medicines from community pharmacies.
Watson MC, Bond CM, Johnston M, Mearns K. Qual Saf Health Care. 2006;15:244-250.
The authors applied human error theory to study consultations for over-the-counter medications in community pharmacies. Their findings suggest that pharmacy staff were unaware of professional guidelines for such communications.
Journal Article > Commentary
Cohen MR. Hosp Pharm. 2006;41:1148-1151.
This monthly report discussed medication reconciliation and community pharmacists, look-alike and sound-alike problems, and automated dispensing cabinet stocking errors.
ISMP Medication Safety Alert! Acute Care Edition. June 28, 2007;12:1-3.
This article discusses inappropriate prescribing of medication patches for acute pain management and provides strategies for minimizing problems associated with their use.
Horsham, PA: Institute for Safe Medication Practices; 2016.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety.
Tools/Toolkit > Toolkit
Horsham, PA: Institute for Safe Medication Practices; 2012.
ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
This newsletter article describes an incident involving a patient who noticed that the tablets in her prescription refill had a different marking than usual, alerting her that she might have received an incorrect medication which was confirmed by the pharmacist. Tips for patients to avoid medication errors include being familiar with how their medicines look and checking prescriptions before leaving the pharmacy. Practitioners can help prevent these errors by counting and labeling prescriptions one at a time and performing patient consultations.
Web Resource > Multi-use Website
American Society of Health-System Pharmacists.
Standardization has been highlighted as a way to improve safety in surgery, care transitions, and medication administration. This initiative seeks to develop consensus guidelines and a set of standard concentrations to reduce errors associated with concentrations and dosing of liquid medications. The process for submitting comments on the first set of materials is open.