Narrow Results Clear All
- Communication between Providers 7
- Education and Training 7
- Error Reporting and Analysis 9
- Human Factors Engineering 6
- Legal and Policy Approaches 3
- Quality Improvement Strategies 8
- Specialization of Care 3
- Technologic Approaches 5
- Transparency and Accountability 1
- Device-related Complications 2
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 5
- Medication Errors/Preventable Adverse Drug Events 21
- Nonsurgical Procedural Complications 2
- Surgical Complications 5
Search results for ""
Web Resource > Database/Directory
Tucson, AZ: University of Arizona Center for Education and Research on Therapeutics, Arizona Health Sciences Center; 2010.
This tool identifies drugs that affect the cardiac conduction system in a deleterious fashion.
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.
Web Resource > Multi-use Website
Foundation for Health Care Quality, 705 2nd Avenue, Suite 703, Seattle, WA 98104.
This coalition supports a network of patient safety professionals to facilitate dialogue, promote initiatives on eliminating wrong-site surgery, and improve medication safety.
Pelczarski K, Fricker M, Morris J. Philadelphia, PA: Health Care Improvement Foundation; 2004.
The Regional Medication Safety Program for Hospitals (RMSPH) implemented a program in 2001 to coordinate the activities of 65 Philadelphia-area hospitals to improve their medication safety administration. The work focused on 16 key improvement areas defined through a collaborative process involving the Health Care Improvement Foundation (HCIF), an affiliate of the Delaware Valley Healthcare Council (DVHC), along with ECRI and the Institute for Safety Medication Practices (ISMP). Tools were developed and disseminated to support improvement efforts at participating hospitals. The report outlines the results of the work and reviews the aggregate data compared to baseline numbers collected in June 2004.
Tools/Toolkit > Fact Sheet/FAQs
Huntingdon Valley, PA: Institute for Safe Medication Practices; 2004.
This booklet provides instructions, recommendations, and safe tips for patients in the hospital, at their doctor's office, or at home. Additional readings are included.
PA-PSRS Patient Saf Advis. June 2006;3:1-5.
This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices. A set of tools for educating hospital personnel about this issue is available via the link below.
Evanston, IL: Office of the Governor; July 13, 2006.
This news release announces the governor's plans to improve patient safety in Illinois, including the use of e-prescribing by all providers and a Division of Patient Safety within the state public health department.
Journal Article > Study
Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system.
Hougland P, Xu W, Pickard S, Masheter C, Williams SD. Med Care. 2006;44:629-636.
This Agency for Healthcare Research and Quality (AHRQ)–supported study evaluated the effectiveness of using designated ICD-9 codes to detect adverse drug events (ADEs). Investigators convened an expert panel to identify codes representing ADEs and then performed retrospective chart reviews with a structured tool to determine the success of this methodology. Overall, flagged ADE codes detected just more than half of ADEs causing hospital admission, making it a readily available tool but not a comprehensive one. Past studies have evaluated the use of ICD-9 codes for similar purposes and for surveillance of device-related hazards.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.
This report shares findings from an expert panel convened to study the causes of medication error in the outpatient setting and provide recommendations for reducing errors associated with prescription and over-the-counter medications.
PA-PSRS Patient Saf Advis. September 2007;4:69, 73-77.
Drawing from data submitted to the Patient Safety Authority reporting system, this article documents factors involved in errors related to medication labels and package design. It also provides risk reduction strategies to minimize such errors.
Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.
Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.
Analyzing patient charts at six community hospitals in Massachusetts, this report reveals to what extent adopting computerized physician order entry could affect clinical outcomes and impart financial savings.
PA-PSRS Patient Saf Advis. March 2008;5:16-18.
Drawing on data from the Patient Safety Authority reporting system, this article describes which medication classes were most frequently associated with patient falls and discusses risk assessment and fall prevention strategies.
PA-PSRS Patient Saf Advis. June 2008;5:53-56.
This article reports on cases of improper IV administration of sterile water, a high-alert substance, for the treatment of hypernatremia and provides risk reduction strategies for this potentially fatal error.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
Chasson L, compiler; Mahoney G, Sherard BD, eds. Cheyenne, WY: Wyoming Department of Health; 2008.
This report aggregates data on adverse events from July 2007 to June 2008 and analyzes the results of data collected in the 3 years since the Wyoming reporting program began.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
PA-PSRS Patient Saf Advis. December 2009;6:109-114.
This article discusses adverse incidents submitted to the Pennsylvania reporting system involving neuromuscular blocking agents and shares strategies to minimize errors with this type of high-alert drug.
Special or Theme Issue
PA-PSRS Patient Saf Advis. December 2009;6(suppl 1):1-32.
Articles in this supplement draw from labor, delivery, and obstetric safety reports to provide insights for safe practice in obstetrics.
PA-PSRS Patient Saf Advis. March 2010;7:9-17.
This article analyzed 2685 event reports involving insulin and found that the most common error types were drug omission, wrong-dose, and wrong-drug errors.