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Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Journal Article > Study
Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.
Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.
Hospitalized children may be particularly vulnerable to medication errors given differences in dosing and monitoring of medications. This study, conducted at five California children's hospitals, used several medication error detection methods to characterize the frequency and types of medication errors in this population. Overall, errors requiring pharmacy intervention occurred at a rate comparable to prior studies, but more errors were detected by using a previously validated trigger tool than by standard voluntary incident reporting. The inability of incident reporting to detect medication errors has been documented in prior research.
Journal Article > Study
Savage I, Cornford T, Klecun E, Barber N, Clifford S, Franklin BD. BMC Health Serv Res. 2010;10:135.
This study used a mixed-methods approach, including structured interviews with staff and patients, to determine the types of errors associated with a newly implemented computerized provider order entry system.
Journal Article > Review
Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Am J Health Syst Pharm. 2011;68:227-240.
Preventing medication errors requires efficient and effective methods to detect them. From incident reporting (IR) systems to trigger tools to MEDMARX, limitations in whether these systems provide a true representation of the problem remain. This systematic review compared different detection methods and found that direct observation captured the greatest number of drug-related problems while IR systems generated the least. However, IR systems demonstrated a higher specificity for severe problems and were generally the least expensive. Trigger tools were the least labor-intensive and most sensitive strategy. The authors conclude that the various detection strategies all have strengths and limitations; however, they seem to capture different drug-related problems, which suggests the need for more than one lens for medication safety detection.
Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.
This article discusses how several health care organizations used health information technology to improve organizational transparency.