Narrow Results Clear All
- Communication Improvement 5
- Education and Training 1
- Error Reporting and Analysis 4
- Human Factors Engineering 4
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Specialization of Care
- Teamwork 1
- Clinical Information Systems 4
- Alert fatigue 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 5
- Psychological and Social Complications 1
Search results for ""
Cases & Commentaries
- Web M&M
Rainu Kaushal, MD, MPH; April 2003
A boy received an overdose of phenytoin due to ambiguous use of abbreviations.
Cases & Commentaries
- Web M&M
William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Special or Theme Issue
Pediatr Crit Care Med. 2007;8(suppl):S1-S43.
This supplement covers issues related to safety indicators, fatigue, electronic medical records, infection, and disclosure of medical errors in the care of critically ill children.
Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275.
This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.
Journal Article > Commentary
Cousins D. Am J Health Syst Pharm. 2009;66:S49-S56.
Reporting on proceedings from a global conference, this commentary reviews consensus statements developed to standardize outcome, process, and structural measures for safe medication practice in hospitals.
Journal Article > Review
Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008.
Semple SJ, Roughead EE. Aust New Zealand Health Policy. 2009;6:24.
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
This article describes how one health care system used a multi-event analysis process to identify medication errors, implement system-level improvements, and reduce adverse events.
Journal Article > Study
Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.
Patients receiving warfarin therapy are at high risk for adverse events. Interventions to improve warfarin safety have focused on trigger tools, communication protocols, and the use of visual medication schedules. This study implemented a pharmacist-directed anticoagulation service to capture inpatients on warfarin and provide them with dosing, monitoring, and coordination of transition from the inpatient to outpatient setting. This cluster randomized trial demonstrated safer transitions in 73% more patients and a 32% reduction in the composite safety end point, which was driven by fewer patients experiencing an INR ≥ 5 (i.e., supratherapeutic levels that increase the risk of bleeding). This study adds further support to the role of pharmacists in driving medication safety, specifically for warfarin in both the inpatient and community settings. A past AHRQ WebM&M commentary discussed a case of a near miss due to a warfarin drug interaction that led to a supratherapeutic level following hospital discharge.