Narrow Results Clear All
- Communication Improvement 14
- Culture of Safety 9
- Education and Training 12
- Error Reporting and Analysis 26
- Human Factors Engineering 7
- Legal and Policy Approaches 5
- Logistical Approaches 1
- Quality Improvement Strategies 14
- Specialization of Care 3
- Teamwork 1
- Technologic Approaches 16
- Transparency and Accountability 1
- Device-related Complications 3
- Discontinuities, Gaps, and Hand-Off Problems 5
- Drug shortages 1
- Identification Errors 3
- Medical Complications 12
- Medication Errors/Preventable Adverse Drug Events
- Overtreatment 2
- Psychological and Social Complications 2
- Surgical Complications 6
- Allied Health Services 1
- Internal Medicine 17
- Surgery 2
- Nursing 2
- Pharmacy 13
- Health Care Executives and Administrators 52
Health Care Providers
- Nurses 5
Non-Health Care Professionals
- Media 1
- Patients 8
- Australia and New Zealand 2
- Europe 14
- Canada 3
- United States of America 46
Search results for "Book/Report"
Brownlee S, Garber J. Brookline, MA: Lown Institute; 2019.
Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, and societal trends of medication overuse and inappropriate polypharmacy in older Americans. A culture of prescribing, deficits in information and knowledge, and fragmented care contribute to the problem. The report provides interventions to improve the safety of prescribing, including developing deprescribing guidelines, raising awareness among providers and patients about medication overload, and implementing team-based care models.
Horsham, PA: Institute for Safe Medication Practices; 2019.
Drug dispensing systems have been adopted in hospitals to prevent medication errors, but accidents associated with their use still occur. This report provides comprehensive guidelines on the safe use of automated dispensing cabinets. Recommendations include improvement in areas such as stocking, labeling, and removal of expired medications.
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.
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.
Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Sheffield, United Kingdom: University of Sheffield and University of York; 2018.
Medication errors represent a significant source of preventable patient harm. Prior research has shown that medication errors occur frequently and are associated with a longer hospital stay and increased costs. This report from the Policy Research Unit in Economic Evaluation of Health and Care Interventions synthesizes the evidence regarding the burden of medication errors in the England. The authors estimate that 237 million medication errors occur annually and that 66 million of these errors may be clinically significant. The majority of potentially harmful errors likely occur in the outpatient setting where most medications in the National Health Service are prescribed. Costs associated with errors seem to vary widely. A prior WebM&M commentary described a case in which a medication error led to serious patient harm.
The STOP Measure. Safe and Transparent Opioid Prescribing to Promote Patient Safety and Reduced Risk of Opioid Misuse.
Washington, DC: America's Health Insurance Plans; 2018.
Disability Law Center. Boston, MA: February 2018.
Patients with mental health concerns are vulnerable to harm from medication errors. This investigation report describes factors that contributed to the deaths of two psychiatric inpatients and identifies weaknesses in monitoring, polypharmacy review, and off-label medication use as primary concerns.
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.
Horsham, PA: Institute for Safe Medication Practices; 2017.
This updated report outlines 14 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press: 2017. ISBN: 9780309461856.
Patient health literacy is a known challenge in health care safety. This publication reports on results of a multidisciplinary workshop that explored health literacy improvement strategies and tools to enhance the clarity of labels, patient instructions, and decision aids to support safe medication use.
Schnell M, Currie J. Cambridge, MA: National Bureau of Economic Research; August 2017. Working Paper No. 23645.
Overprescribing is seen as a contributor to the current opioid epidemic. This working paper explores the potential role that physician education and medical school quality have on prescribing behaviors. Analyzing data from 2006–2014, the authors found that lower ranked institutions wrote more opioid prescriptions and conclude that physician education may be a logical focus of improvement efforts. A recent PSNet perspective explored opioid overdose as a patient safety problem.
Boston, MA: CRICO Strategies; 2017.
Medication errors are a persistent challenge in health care that can occur at home or in the hospital. This analysis of more than 3000 medication-related malpractice claims found that 1 in 9 malpractice cases were associated with medication problems. The majority of medication safety incidents involved primary care providers or hospital-based nurses, and drugs commonly involved included analgesics, anticoagulants, and antibiotics.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2017.
Medication safety is a global health care concern. This workshop proceedings report highlights expert opinion on how to improve the clarity of medication information and the way it is communicated to patients. Panelists focused on elements of the process such as the patient experience, health literacy, medication instructions, and design of medication packaging.
Electronically Generated Medication Administration and Electronic Medication Administration Records for the Prevention of Medication Transcription Errors: Review of Clinical Effectiveness and Safety.
Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2016.
Horsham, PA: Institute for Safe Medication Practices; 2016.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety.
Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.
Standard term selection tools—like pick lists or drop-down menus—in information technology can create opportunities for user error due to human factors. This publication explores how mistakes such as selecting the wrong drug from an ordering pick list can occur in the ambulatory environment. The report includes recommendations and resources to help enhance medication safety when using these tools.
Chicago, IL: American Hospital Association, Health Research & Educational Trust; 2016.
Checklists are a recommended method to reduce omissions in care, despite controversies regarding their impact on safety. This toolkit provides a collection of checklists that have been developed and field tested by participants in the Hospital Engagement Network to prevent harm associated with the use of central lines, adverse drug events, and falls.
National Quality Partners. Washington, DC: National Quality Forum; 2016.
Antimicrobial stewardship has been promoted as a strategy to improve patient safety by reducing overuse of antibiotics to prevent hospital-acquired infections. This report draws from the experience of existing programs to summarize practical strategies for implementing initiatives. Core elements include engaging leadership, monitoring effectiveness, and reporting benchmarks.
Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors.
Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US Food and Drug Administration; December 15, 2015.
Electronic prescribing, considered an opportunity to reduce medication errors, has been linked to problems unique to technology use. This white paper discusses the results of a multi-hospital effort to develop a process and tools to collect and analyze data related to search, display, and workflow issues associated with computerized provider order entry. The authors offer recommendations to enhance the safety of electronic prescribing, including standardizing drug names, minimizing the number of alerts, and designing better search functions.
Pharmacovigilance Risk Assessment Committee. London, UK: European Medicines Agency; 2015.
Medication error reporting data can be utilized to guide improvements worldwide. This report series outlines actions needed to enhance medication safety across the European Union. Recommendations include expanding the definition of adverse reaction to include medication errors and encouraging information sharing about near misses and incidents that result in patient harm.