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- Communication Improvement 5
- Culture of Safety 3
- Education and Training 3
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Logistical Approaches 2
- Quality Improvement Strategies 2
- Technologic Approaches 2
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Journal Article > Study
Medication error in the care of HIV/AIDS patients: electronic surveillance, confirmation, and adverse events.
Delorenze GN, Follansbee SF, Nguyen DP, et al. Med Care. 2005;43(suppl 9):III63-III68.
This AHRQ-funded retrospective study of 5473 patient encounters found that reviewing electronic pharmacy records could help identify preventable medication errors (particularly the use of contraindicated medications) in HIV-infected outpatients.
Journal Article > Study
Kaushal R, Goldmann DA, Keohane CA, et al. Ambul Pediatr. 2007;7:383-389.
The incidence of adverse drug events (ADEs) among children has been well characterized in hospital inpatients, but less studied in the outpatient setting. Conducted at six pediatric outpatient practices, this AHRQ-funded prospective cohort study evaluated the frequency of medication errors via chart review, review of prescriptions, and patient surveys. The overall rate of preventable ADEs was similar to a prior outpatient study, but nearly three-quarters of events were attributable to errors in administering drugs by the parents. Parents also did not consistently inform clinicians of ameliorable ADEs when they occurred, leading the authors to conclude that communication between clinicians and parents around the issue of medication side effects must be improved.
Journal Article > Study
Shehab N, Patel PR, Srinivasan A, Budnitz DS. Clin Infect Dis. 2008;47:735-743.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 6, 2008.
This announcement recalls a mislabeled single-use, disposable syringe that could potentially cause dangerous insulin dosing errors.
Grant > Government Resource
AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care.
Rockville, MD: Agency for Healthcare Research and Quality; October 2008.
This AHRQ grantee announcement lists 13 projects funded to demonstrate effective strategies in identifying and addressing risks and in improving processes in ambulatory care.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 25, 2009.
This announcement explains the potential for medication errors due to a discrepancy between dosing instructions and dosing dispenser measurement units for the drug Tamiflu.
Fitzpatrick C. Consumer Updates. Silver Spring, MD: US Food and Drug Administration. September 29, 2009.
This video for consumers shares tips to avoid medication errors through improved communication, medication information review, and dosage measurement.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; July 2018.
This survey and accompanying toolkit were developed to collect opinions of community pharmacy staff on the safety culture at their pharmacies. The data collection process for the latest national comparison is now closed.
Web Resource > Government Resource
US Food and Drug Administration.
This Web site raises awareness of risks associated with buying medications from online pharmacies and offers resources to help identify whether an online pharmacy is safe or fake.
Tools/Toolkit > Fact Sheet/FAQs
Silver Spring, MD: US Food and Drug Administration; May 2011.
This flyer provides tips to help prevent consumer medication errors.
Rockville, MD: Agency for Healthcare Research and Quality; August 2013. AHRQ Publication No. 13-0067-EF.
This report summarizes findings from projects that explored how health information technology can augment quality and safety in ambulatory care.
Famolaro T, Yount N, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2015. AHRQ Publication No. 15-0041-EF.
This survey expands AHRQ's patient safety culture work to the community pharmacy setting. Approximately 1600 pharmacy staff from 255 community pharmacies voluntarily completed the survey between 2013 and 2014. The database is meant to allow for comparison and benchmarking of safety cultures across pharmacies. However, the current response rate represents less than 1% of total community pharmacies in the United States, and more than half of respondents were chain drugstores or integrated health systems. Most community pharmacies scored well for patient counseling and communication openness, while staffing, work pressure, and pace represented the biggest areas for potential improvement. A prior AHRQ WebM&M interview with J. Bryan Sexton explored the relationship between culture and patient safety.
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.