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- Communication Improvement 3
- Education and Training 3
- Human Factors Engineering 1
- Quality Improvement Strategies 3
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Drug shortages 1
- Medical Complications 1
- Medication Safety 6
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Journal Article > Study
Hayward RA, Asch SM, Hogan MM, Hofer TP, Kerr EA. J Gen Intern Med. 2005;20:686-691.
This retrospective cohort study conducted reviews of both inpatient and outpatient medical records to determine the incidence and types of errors identified. Using a random sample of more than 600 patients from a Veterans Affairs health care system, investigators discovered nearly 3000 errors. The large majority of errors were attributed to the underuse of care, particularly in patients suffering from chronic diseases. The authors conclude that safety efforts and ongoing quality improvement should focus as much on errors of omission as they do on errors of commission.
Food and Drug Administration (FDA) Patient Safety News. Show #60. February 2007.
This video segment shares recommendations for providers about safe prescribing of methadone for pain control, including heightened patient monitoring and encouraging patients to ask questions about how the drug will affect them.
Journal Article > Study
Weiner SJ, Schwartz A, Weaver F, et al. Ann Intern Med. 2010;153:69-75.
The landmark Institute of Medicine report on patient safety categorized inappropriate plans of care as a medical error. This broad classification encompassed decision-making errors by clinicians that included diagnostic errors but also the notion of contextual errors. The latter are those that occur because of inattention to patient context such as environment, behavior, economic situation, or access to care and social support. This study used unannounced standardized patients who acted out four clinical scenarios presenting with biomedical and contextual complicating factors. Attending physicians probed fewer contextual red flags than biomedical ones and provided error-free plans of care in 73% of the uncomplicated encounters, 22% of the contextually complicated encounters, and only 9% of the combined biomedically and contextually complicated encounters. The authors advocate for greater attention and performance metrics to assess how well providers deliver individualized patient care plans based on probed contextual factors.
Silver Spring, MD: US Food and Drug Administration; October 31, 2011.
This report outlines the complex nature of drug shortages and suggests strategies to augment the FDA's efforts to address them.
Web Resource > Multi-use Website
Medical Product Safety Network. Silver Spring, MD; US Food and Drug Administration.
This Web site provides information about tubing misconnections and how to prevent them.
Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 15, 2012.
This announcement reveals risks associated with administering codeine after a common pediatric procedure.
Agency for Healthcare Research and Quality. Research Activities. May 2013:1, 3-4.
This newsletter article describes the development of the Medications at Transitions and Clinical Handoffs (MATCH) toolkit and relates one hospital's experience implementing it.
FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 23, 2013.
This announcement explains a label change to a medication patch intended to reduce risk of accidental exposure.
Tools/Toolkit > Fact Sheet/FAQs
Silver Spring, MD: US Food and Drug Administration; April 2014.
This fact sheet describes five ways patients can contribute to and ensure safe medication use, including speaking up about medical history, asking questions, and following directions on prescription labels. A question guide is also provided to help consumers become informed about their medications.
Journal Article > Commentary
Ellingson K, Haas JP, Aiello AE, et al. Infect Control Hosp Epidemiol. 2014;35:937-960.
Hand hygiene adherence is a key target for improving patient safety. This guideline offers an overview of evidence-based strategies to monitor and promote hand hygiene, including resources developed by the Centers for Disease Control and Prevention and the World Health Organization's "5 moments" program. The authors provide detailed practice recommendations to increase hand hygiene compliance as a way to reduce health care–associated infections.