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- Patient Safety Primers 1
- WebM&M Cases 1
- Perspectives on Safety 2
- Review 5
- Study 22
- Slideset 1
- Book/Report 14
- Legislation/Regulation 4
- Newspaper/Magazine Article 10
- Web Resource 13
- Grant 1
- Meeting/Conference 1
- Press Release/Announcement 3
- Communication Improvement 9
- Culture of Safety 4
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 14
- Human Factors Engineering 10
Legal and Policy Approaches
- Regulation 11
- Logistical Approaches 1
- Quality Improvement Strategies 19
- Research Directions 3
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 16
- Alert fatigue 1
- Device-related Complications 5
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems 3
- Drug shortages 2
- Identification Errors 2
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events
- Overtreatment 1
- Psychological and Social Complications 4
- Surgical Complications 8
- Allied Health Services 1
- Medicine 46
- Nursing 3
- Pharmacy 21
- Family Members and Caregivers 2
- Health Care Executives and Administrators 56
Health Care Providers
- Nurses 3
- Physicians 10
Non-Health Care Professionals
- Media 1
- Patients 12
- Africa 1
- Australia and New Zealand 1
- Europe 9
- Canada 2
Search results for ""
Cases & Commentaries
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Perspectives on Safety > Interview
Workarounds, August 2009
Patient Safety Primers
Over the past decade, the opioid epidemic has taken the lives of tens of thousands of patients. Much of the epidemic can be ascribed to inappropriate prescribing of opioids, despite knowledge of the safety risks they pose. Current efforts to improve opioid safety have primarily focused on reducing opioid prescribing.
Legislation/Regulation > Government Resource
US Food and Drug Administration, HHS. Final rule. Fed Regist. February 26, 2004;69(38):9119-9171.
The US Food and Drug Administration (FDA) requires certain human drug and biological product labels to contain bar codes. The rule aims to reduce the number of medication errors by allowing health care professionals to use bar code scanning equipment for necessary verification. This protects against an incorrect drug administration. Effective date: April 26, 2004.
Wong J, Beglaryan H. Toronto, Ontario: The Change Foundation; February 2004.
A literature review of preventable adverse events in acute-care hospitals. Full analysis and recommendations are provided based on the research findings and input from an expert panel.
Journal Article > Study
Fialová D, Topinková E, Gambassi G, et al. JAMA 2005;293:1348-1358.
This retrospective cross-sectional study of nearly 3000 elderly patients aimed to estimate the prevalence of inappropriate medication use. Investigators studied participants from several European cities and found that nearly 20% used at least one inappropriate medication. Discussion includes a detailed table comparing three different criteria systems for identifying inappropriate medications in the elderly as well as comparisons of the findings in this study with those in the United States. The authors also describe noted regional differences within European cities and report a number of factors associated with inappropriate use, including poor economic situation, polypharmacy, and depression. They authors call for greater regulatory measures and uniformity within the European Union to improve prescribing habits for the elderly.
Journal Article > Commentary
Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.
Clark PA. J Law Med Ethics. 2004;32:349-357.
In this article, the author urges the medical community to universally apply the systems approach to safety toward the reduction of medical errors. The author calls for health care to take medication errors more seriously and for patients to help drive improvement.
Legislation/Regulation > Federal Legislation
HR 2234, 109th Cong, 1st Sess (2005).
This bill, which garnered bipartisan support, proposes developing health information technology networks (known as "Regional Health Information Organizations," or RHIOs) with a strong focus on state- and community-based efforts. It is presently under consideration in the United States House of Representatives.
Journal Article > Study
Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.
Briesacher B, Limcangco R, Simoni-Wastila L, Doshi J, Gurwitz J. J Am Geriatr Soc. 2005;53:991-996.
This study explored the effect of a Centers for Medicare and Medicaid Services policy on inappropriate medication use in nursing homes. The authors conclude that the effect of nationally mandated drug reviews is unclear and suggest that more effective safeguards are needed.
Journal Article > Study
Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.
To grade progress since release of the landmark Institute of Medicine (IOM) report, this AHRQ-funded study examined the status and evolution of patient safety systems through a survey of acute care hospitals in Missouri and Utah. Investigators characterized their assessment based on variables that included presence of computerized physician order entry systems, computerized test results, evaluation of adverse drug events, specific patient safety policies, use of data in patient safety programs, drug administration and safety procedures, error reporting processes, prevention policies, and root cause analyses. More than 100 hospitals completed the survey in 2002 and again in 2004. Findings demonstrated only modest improvements in certain areas with variability noted in others. For instance, surgical areas and medication processes seemed to embrace the greatest level of patient safety systems. However, the authors point out that the overall findings fall short of the IOM recommendations and necessitate a more intensive agenda for accelerated improvements. An accompanying editorial (link below) provides an overview of the factors and challenges involved in promoting change to improve patient safety.
Journal Article > Review
Systematic review: impact of health information technology on quality, efficiency, and costs of medical care.
Chaudhry B, Wang J, Wu S, et al. Ann Intern Med. 2006;144:742-752.
This AHRQ–funded study evaluated more than 250 publications in determining the major studied benefits of health information technology (HIT). The benefits reported include improved adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. In addition, although decreased utilization of care was noted, specific time utilization measures and empirical cost data were either mixed or limited. The authors caution that translating the benefits reported in these high-quality studies may be limited, owing to their evaluation in four benchmark research institutions. The authors discuss the implications of their findings in the context of existing political and financial drivers. This systematic review builds on past studies that focused on specific aspects of HIT, such as computerized provider order entry (CPOE).
Ostrom CM. Seattle Times. June 22, 2006:B1.
This article reports on a Washington state law that prevents pharmacists from accepting prescriptions that are handwritten unless they are very clearly printed.
Evanston, IL: Office of the Governor; July 13, 2006.
This news release announces the governor's plans to improve patient safety in Illinois, including the use of e-prescribing by all providers and a Division of Patient Safety within the state public health department.
Wahlberg D. Wisconsin State Journal. July 22, 2006:A1.
This article reports on a federal warning issued to a hospital after a medication error led to the death of a 16-year-old girl.
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.
Beyzarov E. Drug Topics / Health-System Edition. September 18, 2006.
This article discusses the contamination and sterility issues inherent in the process of compounding drugs.
Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.
This article reports on criminal charges brought against a nurse after she committed a medication error.
Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.