Narrow Results Clear All
- Communication Improvement 12
- Culture of Safety 1
- Education and Training 9
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies
- Specialization of Care 3
- Teamwork 1
- Technologic Approaches 4
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medication Errors/Preventable Adverse Drug Events 9
Search results for ""
Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Tools/Toolkit > Toolkit
Tucson, AZ: University of Arizona Center for Education and Research on Therapeutics; Arizona Health Sciences Center.
This form allows consumers to record relevant information about their (or a family member's) prescription or non-prescription medications, vitamins, herbal therapy, or dietary supplements.
Chun D. Gainsville Sun. August 21, 2006.
This article describes a computerized drug ordering and dispensing system at a Florida hospital.
Foreman J. Los Angeles Times. September 4, 2006:F3.
This article describes what patients can do to minimize opportunities for medication error.
Bethesda, MD: National Council on Patient Information and Education; August 2007.
This report discusses poor medication adherence as a public health issue, describes contributing factors, and outlines a 10-step action plan to improve adherence.
Tarkan L. New York Times. September 14, 2008;Health section:7.
This article describes how medical errors may cause serious harm in pediatric patients and offers tips for hospitals and parents to foster safe treatment.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. September 24, 2008;(41):1-4.
Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission.
Haiken M. Caring.com. August 17, 2009.
To help consumers use medications safely, this article describes 10 common medication mistakes and provides tips on how effective communication and clarification can prevent them.
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.
Journal Article > Study
Cumbler E, Wald H, Kutner J. J Hosp Med. 2010;5-83-86.
The Joint Commission requires that hospitals encourage patients' involvement in their own safety as one of the National Patient Safety Goals. Although patients have expressed concerns about being perceived as challenging their physicians if they ask questions regarding their care, prior research has shown that patients are willing to ask questions about their medications. However, this cross-sectional study showed that hospitalized patients are often unaware of their medications, with patients overall being able to name fewer than half of their medications correctly. Engaging patients in safety efforts may therefore require intensive educational efforts and improved communication as well as encouraging a culture of safety.
Journal Article > Study
Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.
Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.
Washington Post; August 31, 2010:HE02.
This newspaper article describes steps patients can take to prevent medication errors in the physician's office, the pharmacy, and at home.
Journal Article > Review
Ostini R, Jackson C, Hegney D, Tett SE. Med Care. 2011;49:24-36.
Clinicians often must have patients discontinue taking inappropriate or potentially harmful medications, in order to minimize adverse effects or eliminate drug–drug interactions. This systematic review found several potentially effective strategies for withdrawing such prescriptions.
Tools/Toolkit > Fact Sheet/FAQs
Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.
This briefing sheet reviews the opportunities, solutions, and drivers for medication safety improvements.
Journal Article > Study
Ensing HT, Vervloet M, van Dooren AA, Bouvy ML, Koster ES. Int J Clin Pharm. 2018;40:712-720.