Narrow Results Clear All
- Communication Improvement 14
- Culture of Safety 9
- Education and Training 12
- Error Reporting and Analysis 26
- Human Factors Engineering 7
- Legal and Policy Approaches 5
- Logistical Approaches 1
- Quality Improvement Strategies 14
- Specialization of Care 3
- Teamwork 1
- Technologic Approaches 16
- Transparency and Accountability 1
- Device-related Complications 3
- Discontinuities, Gaps, and Hand-Off Problems 5
- Drug shortages 1
- Identification Errors 3
- Medical Complications 12
- Medication Errors/Preventable Adverse Drug Events
- Overtreatment 2
- Psychological and Social Complications 2
- Surgical Complications 6
- Allied Health Services 1
- Internal Medicine 17
- Surgery 2
- Nursing 2
- Pharmacy 13
- Health Care Executives and Administrators 52
Health Care Providers
- Nurses 5
Non-Health Care Professionals
- Media 1
- Patients 8
- Australia and New Zealand 2
- Europe 14
- Canada 3
- United States of America 46
Search results for "Medication Errors/Preventable Adverse Drug Events"
- Medication Errors/Preventable Adverse Drug Events
Department of Health and Social Care. London, England: Crown Publishing; February 2018.
Medication errors are a prominent challenge for health care systems worldwide. This report provides recommendations that align with the World Health Organization medication safety improvement effort to address medication failures in the National Health Service. The authors suggest an emphasis on technology, teamwork, and safety culture to enable sustained improvements across the system.
Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Sheffield, United Kingdom: University of Sheffield and University of York; 2018.
Medication errors represent a significant source of preventable patient harm. Prior research has shown that medication errors occur frequently and are associated with a longer hospital stay and increased costs. This report from the Policy Research Unit in Economic Evaluation of Health and Care Interventions synthesizes the evidence regarding the burden of medication errors in the England. The authors estimate that 237 million medication errors occur annually and that 66 million of these errors may be clinically significant. The majority of potentially harmful errors likely occur in the outpatient setting where most medications in the National Health Service are prescribed. Costs associated with errors seem to vary widely. A prior WebM&M commentary described a case in which a medication error led to serious patient harm.
Disability Law Center. Boston, MA: February 2018.
Patients with mental health concerns are vulnerable to harm from medication errors. This investigation report describes factors that contributed to the deaths of two psychiatric inpatients and identifies weaknesses in monitoring, polypharmacy review, and off-label medication use as primary concerns.
Weiss AJ, Freeman WJ, Heslin KC, Barrett ML. HCUP Statistical Brief #234. Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
Adverse drug events (ADEs) are common and can result in patient harm. This report analyzes data from the Healthcare Cost and Utilization Project to compare characteristics of hospital inpatient stays involving an ADE from 2010 and 2014. Information revealed by the data include impacts on length of stay, average costs, and whether the ADE occurred in the hospital or prior to admission.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press: 2017. ISBN: 9780309461856.
Patient health literacy is a known challenge in health care safety. This publication reports on results of a multidisciplinary workshop that explored health literacy improvement strategies and tools to enhance the clarity of labels, patient instructions, and decision aids to support safe medication use.
Pharmacovigilance Risk Assessment Committee. London, UK: European Medicines Agency; 2015.
Medication error reporting data can be utilized to guide improvements worldwide. This report series outlines actions needed to enhance medication safety across the European Union. Recommendations include expanding the definition of adverse reaction to include medication errors and encouraging information sharing about near misses and incidents that result in patient harm.
Leeds, UK: Health and Social Care Information Centre; 2018.
This report identified a significant number of medication errors associated with diabetes care in acute hospitals in England and Wales.
Cima L, Clarke S, eds. Oakbrook Terrace, IL: Joint Commission; 2012. ISBN: 9781599406183.
Exploring nurses' role in care delivery and medication safety, this publication provides strategies for nurses to improve safety.
Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency for Healthcare Research and Quality; April 2011.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Adlassnig KP, Blobel B, Mantas J, Masic I, eds. Stud Health Technol Inform. 2009;150:497-566. In: Medical Informatics in a United and Healthy Europe. Washington, DC: IOS Press. ISBN: 9781607500445.
Part of a comprehensive electronic compilation on medical informatics, this series of papers examines topics surrounding the use of health information technology (HIT) to detect, report, and learn from adverse events.
London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.
This publication analyzes 72,482 medication incidents reported to the National Health Service and highlights areas for improvement and prevention.
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.
Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.
This report summarizes findings from interviews with AHRQ-funded grantees who have implemented computerized provider order entry systems.
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.
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.
Fitzpatrick J, Stone P, Hinton-Walker P, eds. Annual Review of Nursing Research. New York, NY: Springer; 2006. ISBN: 0826141366.
This volume includes research and reviews related to patient safety standards and practices in nursing.
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.
Research in Action, Issue 1. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication 01-0020.
Adverse drug events (ADEs) result in more than 770,000 annual injuries and deaths with significant resulting costs. Hospitals can reduce this burden by promoting system changes to better detect and prevent ADEs. Successful approaches are summarized.
Brownlee S, Garber J. Brookline, MA: Lown Institute; 2019.
Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, and societal trends of medication overuse and inappropriate polypharmacy in older Americans. A culture of prescribing, deficits in information and knowledge, and fragmented care contribute to the problem. The report provides interventions to improve the safety of prescribing, including developing deprescribing guidelines, raising awareness among providers and patients about medication overload, and implementing team-based care models.