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- Communication between Providers 21
- Culture of Safety 4
- Education and Training 17
- Error Reporting and Analysis 21
- Human Factors Engineering 14
- Legal and Policy Approaches 14
- Logistical Approaches 8
- Quality Improvement Strategies 32
- Specialization of Care 5
- Teamwork 1
- Clinical Information Systems 11
- Alert fatigue 1
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 9
- Drug shortages 3
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 59
- Psychological and Social Complications 1
- Second victims 1
- Allied Health Services 1
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- Nursing 5
- Pharmacy 83
- Health Care Executives and Administrators 36
Health Care Providers
- Nurses 23
- Physicians 29
- Non-Health Care Professionals 17
- Patients 15
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
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.
Wild D. Pharmacy Practice News. November 8, 2018.
Medication safety officers serve as organizational champions of medication management process improvement. This news article offers two examples of health care organizations that positioned medication safety officers as leaders in their systems. The piece describes improvements stemming from employment of medication safety officers at these organizations.
Peeples L. Pharmacy Practice News. October 10, 2018.
Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.
Sederstrom J. Drug Topics. September 17, 2018.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.
Decerbo M. Pharmacy Practice News. September 13, 2018.
Parenteral nutrition errors can result in patient malnutrition and harm. Reporting on how insufficient understanding of malnutrition contributes to its presence in health care, this news article suggests that both general guidelines and tailored approaches to nutrition are necessary to keep hospitalized patients safe. Improvements in addressing the complicated needs of patients who are older or have cancer illustrate progress made toward the effective delivery of nutrition.
ISMP Medication Safety Alert! Acute Care Edition. October 19, 2017;22:1-3.
Blank C. Drug Topics. October 13, 2017.
ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.
Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.
Straka M, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. June 2017;14:55-63.
According to this analysis of more than 1000 reports of errors occurring in community pharmacies, more than half reached the patient. Common error types included wrong drug and wrong dose incidents. Counseling patients on their medications at the point of sale can improve the reliability of outpatient pharmacy practice.
ISMP Medication Safety Alert! Acute Care Edition. August 25, 2016;21:1-3.
Reporting the results of a survey on "as directed" instructions for medications and summarizing cases of misunderstandings resulting from the practice, this newsletter article recommends that physicians should provide explicit directions regarding medication administration steps to patients to ensure medications are used safely and pharmacists are able to provide appropriate patient counseling if required.
ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6.
Neuromuscular blockers can result in serious harm if administered incorrectly. This newsletter article reports the types of errors associated with the use of these high-alert medications, such as look-alike and sound-alike problems that lead to the wrong drug being administered. Recommended strategies to reduce risks include use of standardized prescribing and smart pump technologies.
Graham LR, Scudder L, Stokowski L. Medscape Multispecialty. October 22, 2015.
Errors in the prescribing process can lead to adverse drug events. This slide set provides information about common problems in prescribing such as selecting the wrong drug in a drop-down menu, formulation mix-ups, alert fatigue, poor quality of data in health information systems, and use of ambiguous abbreviations.
ISMP Medication Safety Alert! Acute Care Edition. January 15, 2015;20:1-4.
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.
Wild D. Pharmacy Practice News. September 8, 2014.
Highlighting how hospital compliance rates with Joint Commission medication–related standards have remained mostly unchanged from 2012 to 2013, this article provides information about the most problematic areas identified—medication storage, drug orders, pharmacist review, labeling, and medication reconciliation—along with ways to address them.
Lefeber J. Patient Saf Qual Healthc. January/February 2014;11:26-28,30-31.
This article reveals the experience of a critical access hospital that used medication reconciliation to expand electronic health record adoption efforts. The author describes challenges hospital leaders faced and makes recommendations for organizations to consider when implementing a medication reconciliation program.
ISMP Medication Safety Alert! Acute Care Edition. November 14, 2013;18:1-4.
This newsletter article reports on concerns associated with chemotherapy preparations due to variations in concentration and recommends standardized preparation processes to address such risks.
Daly M, Lee B. Formulary. August 8, 2013.
This article examines the value of medication reconciliation as a strategy to improve safety and reveals its potential to save costs.
ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.
This newsletter article details the characteristics of successful community liaison programs, which facilitate transitions from hospital to home, and describes how such programs can reduce the risk of medication discrepancies.
Murray C, Rycek W, Johnson D, Sifuentes-Tovar F. Pharm Purch Prod. January 2013;10:12.
This magazine article details how one academic medical center used a collaborative approach and implemented policies and procedures to address perioperative drug shortages.