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- Quality Improvement Strategies 4
- Teamwork 2
- Technologic Approaches 7
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Cases & Commentaries
- Spotlight Case
- Web M&M
Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD; September 2016
An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.
Journal Article > Study
Porter SC, Kohane IS, Goldmann DA. J Am Med Inform Assoc. 2005;12:299-305.
This study examined the utility of a multimedia kiosk to capture parents' knowledge of their children's asthma medication history. Investigators compared the parental information with that documented by emergency department providers. Results suggested greatest accuracy in medication name followed by route of delivery, form of medication, and dose. The authors conclude that patient-derived data can be effective in improving current deficits in medication documentation during emergency department visits.
Young D. Am J Health Syst Pharm. 2005;62:1340-1342.
This article summarizes comments made at the second meeting of the Committee on Identifying and Preventing Medication Errors. Topics covered include teamwork, engaging patients, medication reconciliation, access to information, and hospital design.
Institute for Healthcare Improvement Web site. March 20, 2006.
This article reviews the importance of medication reconciliation, discusses the difficulties of building the process into patient care, and shares stories from hospitals that have successfully implemented programs.
Landro L. Wall Street Journal (Eastern edition). May 23, 2006:D1. [reprinted on Post-Gazette.com]
This article discusses the shared responsibility among patients, hospitals, and practitioners to support appropriate drug administration through medication reconciliation.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Markel H. New York Times. February 25, 2007;4:5.
This article discusses the problems associated with taking many prescription and over-the-counter medications, as dangerous combinations may go undetected.
Tools/Toolkit > Toolkit
Massachusetts Coalition for the Prevention of Medical Errors, Betsy Lehman Center for Patient Safety and Medical Error Reduction, Massachusetts Medical Society.
This form can help patients document their prescriptions and other health information prior to visits with health care providers.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
Tools/Toolkit > Government Resource
Leonhardt K, Bonin K, Pagel P. Rockville, MD: Agency for Healthcare Research and Quality; April 2008. AHRQ Publication Nos. 080048.
This AHRQ-funded toolkit outlines how one Midwestern hospital system successfully implemented a patient advisory council. A companion toolkit illustrates how the council worked with the hospital to develop and implement a medication list initiative.
Cooney E. Worcester Telegram & Gazette. January 28, 2008;Living section:E1.
This article discusses an AHRQ-funded program to study information technology tools and their ability to minimize medication errors in a geriatric patient population.
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.
Rockville, MD: Agency for Healthcare Research and Quality. September 29, 2010.
This trio of public service announcements promotes safe medication use, informed discharge, and family and friends as advocates in the hospital.
Landro L. Wall Street Journal. June 9, 2014.
As they become more prevalent, electronic medical records (EMRs) are being used to improve safety in increasingly creative ways. This newspaper article reports on efforts to engage patients in reviewing their medication lists by providing them with access to EMR systems in order to detect and correct discrepancies in data.
Silver Spring, MD: US Food and Drug Administration. Office of Women's Health and National Association of Chain Drug Stores.
This toolkit offers tips for patients to prevent adverse drug events and provides a way to record important medication information such as a list of allergies, prescriptions, dosages, and conditions being treated.
Gorman A. Kaiser Health News. August 30, 2016.
Older patients are particularly vulnerable to medication errors, as they are often prescribed multiple medications for chronic conditions. This news article reports on complexities associated with managing medications in older patients, including how miscommunication between care team members and patient misunderstanding of postdischarge medication changes can increase risks and contribute to preventable harm. A recent WebM&M commentary discussed strategies to safely manage medications in older patients and highlighted the importance of medication reconciliation.