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Search results for ""
Journal Article > Commentary
Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge.
Rodehaver C. Jt Comm J Qual Patient Saf. 2005;31:406-413.
The Joint Commission on Accreditation of Healthcare Organization's (JCAHO) National Patient Safety Goals advocate for hospitals to ensure medication reconciliation as part of their safety strategy. This article shares the views of a single institution in its efforts to construct reconciliation forms, design processes for use, and then audit the forms after put into practice. The authors offer a series of lessons learned from their implementation experience and suggest that future success relies on a team-oriented approach with consistent communication.
Legislation/Regulation > Sentinel Event Alerts
The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued this alert to bring attention to a rare but potentially severe administration error reported with the cancer drug vincristine. A previous editorial discusses similar errors.
Vecchione A. Drug Topics. July 11, 2005;149:24.
This article summarizes the 2006 Joint Commission on Accreditation of Healthcare Organizations patient safety goals and how hospital pharmacists can contribute to their successful implementation.
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.
Thompson CA. Am J Health Syst Pharm. 2005;62:1528-1532.
This article reports on the Joint Commission on Accreditation of Healthcare Organizations' medication reconciliation goal and the problems hospitals may encounter when implementing a medication reconciliation program.
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.
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.
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
Brown CA, Bailey JH, Lee J, Garrett PK, Rudman WJ. Am J Med Sci. 2006;331:22-24.
The investigators conducted focus groups with pharmacists and patients in order to better understand the ambulatory pharmacist's role in mitigating and reporting medication errors. They found that pharmacists play an important role in intercepting errors but do not always report them to physicians.
Journal Article > Commentary
Pharmacy clarification of prescriptions ordered in primary care: a report from the Applied Strategies for Improving Patient Safety (ASIPS) collaborative.
Hansen LB, Fernald D, Araya-Guerra R, Westfall JM, West D, Pace W. J Am Board Fam Med. 2006;19:24-30.
The investigators in this Agency for Healthcare Research and Quality-sponsored study determined that pharmacists contact primary care practices most frequently to clarify prior authorization, formulary issues, and unclear or missing dosages.
Journal Article > Study
Durbin J, Hansen MM, Sinkowitz-Cochran R, Cardo D. Am J Infect Control. 2006;34:25-30.
The investigators surveyed health care providers to determine their perceptions on patient safety in the health care system. They found that clinicians believed systemwide interventions and stronger patient involvement would improve safety.
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.
Institute for Healthcare Improvement Web site. March 20, 2006.
This article reviews the importance of medication reconciliation, discusses the difficulties of building the process into patient care, and shares stories from hospitals that have successfully implemented programs.
Cassell DK. Drug Topics: Health-System Edition. March 20, 2006.
This article shares strategies to minimize insulin medication errors, including educating about dangerous abbreviations, developing strict formularies, and using independent double checks.
ISMP Medication Safety Alert! Acute Care Edition. April 21, 2005;10:1-2.
This article presents examples of medication errors caused by failed communication, briefly reviews the steps for medication reconciliation, and includes a survey to assess progress with the Joint Commission on Accreditation of Healthcare Organizations' patient safety goals.
Journal Article > Review
Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Arch Intern Med. 2006;166:955-964.
This systematic review evaluated 36 studies that encompassed pharmacy participation in patient rounds and medication reconciliation efforts as well as drug-specific pharmacist services. The authors detail the individual and collective findings, which include reductions in adverse drug events or errors in more than half the trials with improvements in medication adherence, knowledge, and appropriateness in a similar proportion. None of the studies demonstrated a worse overall outcome, and only one suggested increased health care utilization. The authors outline the needs for future investigation around roles for clinical pharmacists, clinical areas and patients most likely to benefit from their services, and better models to determine cost effectiveness.
PA-PSRS Patient Saf Advis. June 2006;3:1-5.
This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices. A set of tools for educating hospital personnel about this issue is available via the link below.
ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.
This article summarizes the results of Institute for Safe Medication Practices' (ISMP's) national survey on medication reconciliation.