Narrow Results Clear All
- Study 12
- Slideset 1
- Book/Report 49
- Legislation/Regulation 9
- Newspaper/Magazine Article 11
- Newsletter/Journal 1
- Special or Theme Issue 2
- Toolkit 15
- Forum 1
- Bibliography 1
- Grant 6
- Meeting/Conference 3
- Press Release/Announcement 44
- Communication between Providers 22
- Culture of Safety 19
Education and Training
- Students 2
Error Reporting and Analysis
- Error Reporting 39
- Human Factors Engineering 30
- Legal and Policy Approaches 29
- Logistical Approaches 7
- Policies and Operations 1
- Quality Improvement Strategies 53
- Research Directions 2
- Specialization of Care 3
- Teamwork 5
- Clinical Information Systems 16
- Transparency and Accountability 3
- Device-related Complications 14
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 17
- Drug shortages 6
- Fatigue and Sleep Deprivation 3
- Identification Errors 8
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 118
- Psychological and Social Complications 5
- Surgical Complications 15
- Allied Health Services 1
- Internal Medicine 41
- Nursing 3
- Pharmacy 71
- Family Members and Caregivers 4
- Health Care Executives and Administrators 127
Health Care Providers
- Nurses 10
- Pharmacists 30
- Physicians 18
Non-Health Care Professionals
- Media 1
- Patients 64
- Australia and New Zealand 3
- Europe 13
- Canada 4
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 141
- United States Federal Government 155
Search results for "Web Resource"
- Web Resource
- Medication Safety
Web Resource > Multi-use Website
National Pharmacy Association. St. Albans, UK.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.
The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Journal Article > Government Resource
Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. MMWR Morb Mortal Wkly Rep. 2019;67:1419-1427.
This Centers for Disease Control and Prevention report provides drug and opioid overdose death figures for 2016. The rate of overdose deaths continues to rise, with the largest increase due to synthetic opioids such as fentanyl. The report calls for enhancing prevention and response measures, including the use of naloxone.
FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
This safety announcement raises awareness of pump failures, dosing errors, and other potential safety issues associated with implanted pumps. Recommendations to enhance safety include review of medication labeling to select appropriate medicines and concentrations as well as open discussions with patients about risks associated with pump and medication options.
Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.
Silver Spring, MD: US Food and Drug Administration; September 29, 2018.
Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015.
Weiss AJ, Heslin KC, Barrett ML, Izar R, Bierman IR. HCUP Statistical Brief #244. Rockville, MD: Agency for Healthcare Research and Quality; September 2018.
Polypharmacy, chronic conditions, and mental health needs can contribute to misuse of opioids. This data analysis from the AHRQ Healthcare Cost and Utilization Project found that opioid-related hospitalizations and emergency room visits for older Americans increased substantially between 2010 and 2015.
Washington DC: National Academy of Medicine and the Aspen Institute.
Despite increased awareness regarding the public health impacts of opioid misuse and overdose in the United States, the complexity of the problem has hindered the effectiveness of improvement efforts. This website highlights the work of a multiorganizational collaborative to explore systemic solutions to address the opioid crisis. An Annual Perspective discussed the impact of the opioid epidemic on patient safety.
Web Resource > Multi-use Website
MacColl Center for Health Care Innovation at the Kaiser Permanente of Washington Research Institute; University of Washington.
In light of the current opioid crisis, the use of opioids to manage noncancer-related chronic pain in the ambulatory environment has been targeted for improvement. This AHRQ-funded initiative offers a six-element multidisciplinary redesign approach that highlights areas such as leadership development, prescription monitoring, and care planning.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Reducing hospital-acquired conditions (HACs) such as health care-associated infections has been a major focus of quality improvement efforts, motivated in part by Medicare nonpayment and reporting. According to the Agency for Healthcare Research and Quality (AHRQ), HAC rates decreased by just over 20% between 2010 and 2015. In this report, AHRQ estimates that between 2014 and 2016, HAC reduction efforts resulted in an 8% decrease in events, $2.9 billion dollars in savings, and the prevention of about 8,000 deaths. While infections and adverse drug events decreased, pressure ulcers increased and represent an opportunity for further improvement. Overall, this report suggests that HAC reduction efforts continue to be successful.
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.
Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380.
Ineffectively prescribed opioids contribute to opioid misuse and overdose among patients. This report analyzed activities at five Veterans Health Administration facilities and found inconsistent application of opioid safety strategies in the system. System-level recommendations to enhance practice include cross-system tracking efforts with defined goals and establishing a pain management leadership role at each facility.
Tools/Toolkit > Government Resource
National Health Service.
Data surveillance and transparency are core to measuring and informing improvement efforts. This website provides detailed data that links ambulatory care prescribing activity to National Health Service hospitalizations in an effort to clarify potential adverse medication events. The dashboard launched tracking gastrointestinal bleeding as an indicator of a medication-related adverse result and will expand to other indicators and conditions over time.
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.
Drug Enforcement Administration. April 28, 2018.
Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.
Journal Article > Government Resource
Vital signs: trends in emergency department visits for suspected opioid overdoses—United States, July 2016–September 2017.
Vivolo-Kantor AM, Seth P, Gladden RM, et al. MMWR Morb Mortal Wkly Rep. 2018;67:279-285.
The opioid epidemic continues unabated in the United States. Although efforts such as the 2016 Centers for Disease Control and Prevention guideline for opioid prescribing have raised awareness and changed practice, rates of opioid-related deaths are still rising. This study reports trends in emergency department visits for opioid overdose between July 2016 and September 2017. Researchers noted a nearly 30% increase in opioid overdose rates. Overdoses increased in all regions and most states, with the most prominent spikes noted in the West and Midwest. This sobering, high-quality, and timely data will inform initiatives to reduce high-risk prescribing, promote medication-assisted treatment, and improve secondary prevention of overdose. An Annual Perspective outlines strategies for mitigating opioid harms.
Department of Health and Social Care. London, England: Crown Publishing; February 2018.
Medication errors are a prominent challenge for health care systems worldwide. This report provides recommendations that align with the World Health Organization medication safety improvement effort to address medication failures in the National Health Service. The authors suggest an emphasis on technology, teamwork, and safety culture to enable sustained improvements across the system.
FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2018.
Weiss AJ, Freeman WJ, Heslin KC, Barrett ML. HCUP Statistical Brief #234. Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
Adverse drug events (ADEs) are common and can result in patient harm. This report analyzes data from the Healthcare Cost and Utilization Project to compare characteristics of hospital inpatient stays involving an ADE from 2010 and 2014. Information revealed by the data include impacts on length of stay, average costs, and whether the ADE occurred in the hospital or prior to admission.
Tools/Toolkit > Government Resource
Centers for Disease Control and Prevention.
The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to raise awareness of the addictive nature of the medication. This national campaign enlists communities and individual clinicians to provide patient education to address the opioid epidemic. The website offers videos and other resources to assist community-level efforts to reduce risk for opioid addiction.