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- Communication between Providers 4
- Education and Training 5
- Error Reporting and Analysis 3
- Human Factors Engineering 5
- Legal and Policy Approaches 1
- Quality Improvement Strategies 4
- Specialization of Care 2
- Technologic Approaches 3
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Tools/Toolkit > Toolkit
Tucson, AZ: University of Arizona Center for Education and Research on Therapeutics; Arizona Health Sciences Center.
This form allows consumers to record relevant information about their (or a family member's) prescription or non-prescription medications, vitamins, herbal therapy, or dietary supplements.
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.
The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.
This report shares findings from an expert panel convened to study the causes of medication error in the outpatient setting and provide recommendations for reducing errors associated with prescription and over-the-counter medications.
PA-PSRS Patient Saf Advis. September 2007;4:69, 73-77.
Drawing from data submitted to the Patient Safety Authority reporting system, this article documents factors involved in errors related to medication labels and package design. It also provides risk reduction strategies to minimize such errors.
Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.
Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.
Analyzing patient charts at six community hospitals in Massachusetts, this report reveals to what extent adopting computerized physician order entry could affect clinical outcomes and impart financial savings.
PA-PSRS Patient Saf Advis. June 2008;5:53-56.
This article reports on cases of improper IV administration of sterile water, a high-alert substance, for the treatment of hypernatremia and provides risk reduction strategies for this potentially fatal error.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
PA-PSRS Patient Saf Advis. December 2009;6:109-114.
This article discusses adverse incidents submitted to the Pennsylvania reporting system involving neuromuscular blocking agents and shares strategies to minimize errors with this type of high-alert drug.
PA-PSRS Patient Saf Advis. June 2010;7:46-51.
This piece characterizes medication storage methods that contribute to adverse drug events and provides suggestions for improvement.
Journal Article > Study
Ernst AA, Weiss SJ, Sullivan A IV, et al. Am J Emerg Med. 2012;30:717-725.
The presence of a pharmacist in the emergency department was associated with fewer medication errors during resuscitations and trauma situations.
PA-PSRS Patient Saf Advis. March 2011;8:1-7.
This piece reports on the prevalence of medication errors in the emergency department and suggests expanding pharmacy involvement as a strategy to reduce risks.
Web Resource > Multi-use Website
Michigan Pharmacists Association.
Journal Article > Study
Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.