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- Communication Improvement 2
- Culture of Safety 1
- Education and Training 2
- Human Factors Engineering 2
- Legal and Policy Approaches 2
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care 2
- Technologic Approaches 4
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications
- Medication Errors/Preventable Adverse Drug Events 4
- Surgical Complications 1
- Allied Health Services 1
- Surgery 1
- Nursing 2
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Cases & Commentaries
- Web M&M
Richard Hellman, MD; March 2007
For a woman with insulin-dependent diabetes mellitus, the admitting medical team ordered sliding scale insulin. Her blood glucose levels became very difficult to control, and she developed diabetic ketoacidosis. In the morning, the physician instituted a more appropriate insulin regimen.
Vecchione A. Drug Topics. July 11, 2005;149:24.
This article summarizes the 2006 Joint Commission on Accreditation of Healthcare Organizations patient safety goals and how hospital pharmacists can contribute to their successful implementation.
Special or Theme Issue
The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.
Journal Article > Commentary
Cohen MR. Hosp Pharm. 2007;42:982-986.
This monthly commentary examines risks associated with mismanagement of IV tubing and ports, discusses a recent article regarding unintended consequences of computerized provider order entry (CPOE), and details recent changes to similarly named medications.
Journal Article > Study
Jennings HR, Miller EC, Williams TS, Tichenor SS, Woods EA. Jt Comm J Qual Patient Saf. 2008;34:196-200.
Hospitalized patients receiving anticoagulants such as warfarin are at high risk for adverse drug events, and reducing the incidence of such errors is one of the Joint Commission's 2008 National Patient Safety Goals. In this study, a hospital system instituted several patient safety measures, including an anticoagulation service and executive walk rounds, to target anticoagulant-related medication errors. The 3-year project resulted in a significant reduction in both bleeding and thrombotic episodes. A case of a warfarin-related adverse event is discussed in an AHRQ WebM&M commentary.
Award > Award Recipient
Washington, DC: Leapfrog Group; September 24, 2008.
This announcement highlights the 33 hospitals recognized for high performance and continuous improvement in patient safety based on the 2008 Leapfrog Hospital Survey results.
Journal Article > Study
From research to practice: factors affecting implementation of prospective targeted injury-detection systems.
Sorensen AV, Harrison MI, Kane HL, Roussel AE, Halpern MT, Bernard SL. BMJ Qual Saf. 2011;20:527-533.
This study explores the barriers five hospitals faced in implementing new systems for prospective detection of adverse drug events and pressure ulcers, and recommends steps organizations can take to ensure smoother implementation.
ISMP Medication Safety Alert! Acute Care Edition. September 20, 2012;17:1,3-4.
Decerbo M. Pharmacy Practice News. September 13, 2018.
Parenteral nutrition errors can result in patient malnutrition and harm. Reporting on how insufficient understanding of malnutrition contributes to its presence in health care, this news article suggests that both general guidelines and tailored approaches to nutrition are necessary to keep hospitalized patients safe. Improvements in addressing the complicated needs of patients who are older or have cancer illustrate progress made toward the effective delivery of nutrition.