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- Legal and Policy Approaches 1
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- Device-related Complications 1
- Medication Errors/Preventable Adverse Drug Events 15
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Search results for "Government Resource"
- Government Resource
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.
FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2018.
FDA Drug Safety Communication: FDA warns about prescribing and dispensing errors resulting from brand name confusion with antidepressant Brintellix (vortioxetine) and antiplatelet Brilinta (ticagrelor).
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; July 30, 2015.
Look-alike and sound-alike drug names can contribute to confusion and result in medication errors. To raise awareness of potential wrong-patient errors due to similarity between two proprietary names, this announcement describes near misses with the drugs at the prescribing and dispensing stage and suggests clinicians use the generic names for the medications to reduce risk of patient harm.
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.
Tools/Toolkit > Fact Sheet/FAQs
Silver Spring, MD: United States Food and Drug Administration; October 31, 2014.
Studies have shown that pharmacist involvement can prevent medication errors. To help patients take their medications safely, this consumer update discusses pharmacists as participants in a government drug information center and reveals the top five questions submitted along with their corresponding answers.
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.
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.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 9, 2008.
This announcement recalls a particular lot of injectable potassium chloride solution due to incorrect barcode labeling, which could result in medication errors.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 18, 2008.
This announcement provides information on a recall of heparin vials due to negative reactions reported with certain batches of the medication.
FDA Public Health Advisory. Silver Spring, MD: US Food and Drug Administration; December 21, 2007.
This Food and Drug Administration public health advisory alerts health care professionals, patients, and their caregivers to the possibility for overdoses of fentanyl in patients using fentanyl skin patches for pain control.
Tools/Toolkit > Government Resource
Jacobson KL, Gazmararian JA, Kripalani S, McMorris KJ, Blake SC, Brach C. Rockville, MD: Agency for Healthcare Research and Quality; 2007. AHRQ Publication No. 07-0051.
This AHRQ-funded publication provides a tool to help organizations identify health literacy issues, as well as methods for implementing an action plan drawn from assessment results.
PA-PSRS Patient Saf Advis. May 2007;4(suppl 2):1-8.
This article shares findings from a workgroup that assessed the efficacy of pharmacy computer systems in detecting unsafe medication orders. The 30 Pennsylvania hospitals that participated in the workgroup found that their systems were not catching all unsafe orders.
Food and Drug Administration (FDA) Patient Safety News. Show #60. February 2007.
This video segment shares recommendations for providers about safe prescribing of methadone for pain control, including heightened patient monitoring and encouraging patients to ask questions about how the drug will affect them.
Meeting/Conference > Government Resource
Public Meeting on Improving Patient Safety by Enhancing the Container Labeling for Parenteral Infusion Drug Products.
US Food and Drug Administration, Center for Drug Evaluation and Research. January 11, 2007.
The US Food and Drug Administration invited experts to comment on how labels for intravenous drugs could be designed to ensure the safe use of these medications through informed label redesign efforts.
Journal Article > Government Resource
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2007;56:1-4.
The Centers for Disease Control and Prevention (CDC) investigated adverse events related to cough and cold medications in infants. The investigation found three instances in which these medications were considered the underlying cause of death.
Food and Drug Administration (FDA) Patient Safety News. Show #59. January 2007.
This video segment warns about potential dosing errors for an epileptic seizure treatment due to equipment design and provides instructions to minimize user error.
Food and Drug Administration (FDA) Patient Safety News. Show #58. December 2006.
This video story reviews a high-profile medication error and suggests actions to prevent similar incidents from occurring.
Tools/Toolkit > Government Resource
Huntington Valley, PA: Institute for Safe Medication Practices.
This Web site includes tools to help raise awareness about potential medication errors associated with using certain abbreviations. The tools are made available by Institute for Safe Medication Practices (ISMP) and U.S. Food and Drug Administration (FDA) as part of their national educational effort to eliminate the use of these abbreviations.
VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.
Washington, DC: United States Government Accountability Office; May 2006. Publication GAO-06-544.
This investigation determined that the U.S. Veterans Administration has taken steps to improve the reliability of their practitioner licensure and certification screening processes for employees and new hires but found that some weaknesses still exist.
VA National Center for Patient Safety. Washington, DC: VA Central Office; April 6, 2006. Patient Safety Alert AL06-012.
This alert reports five instances of accidental infusion into an IV or peripherally inserted central catheter (PICC) line and suggests actions for preventing similar errors.