Narrow Results Clear All
- Communication Improvement 14
- Culture of Safety 3
- Education and Training 7
- Error Reporting and Analysis 10
- Human Factors Engineering 5
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 14
- Specialization of Care 4
- Clinical Information Systems 6
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 5
- Drug shortages 3
- Medication Errors/Preventable Adverse Drug Events 13
- Surgical Complications 1
- Australia and New Zealand 1
- Europe 5
- North America 33
Search results for "Pharmacy"
1000 Lives Plus. Cardiff, Wales: National Health Services Wales; 2012.
Building on a multidisciplinary improvement model, this guide provides techniques to help pharmacists improve medication safety through system and process redesign.
Sarasohn-Kahn J, Holt M. Oakland, CA: California Healthcare Foundation; 2006. ISBN: 1933795026.
This report outlines the prescription process and the potential improvements in cost, efficiency, compliance, and safety that could be gained through implementation of e-prescribing.
Geneva, Switzerland: World Health Organization; 2019.
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.
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.
Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care admissions, emergency department use, ambulatory adverse events, and elderly patients affected by medication-related problems. Pharmacists are emphasized as pivotal to medication safety improvement efforts.
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.
Horsham, PA: Institute for Safe Medication Practices; May 2017.
Insulin is a widely used medication that can contribute to serious patient harm if used incorrectly. This report provides information about problems associated with insulin use in adults and offers consensus-developed strategies to encourage subcutaneous insulin practices that reduce errors at the prescribing, pharmacy management, administration, and transition phases.
Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy and Management at Brandeis University; 2016.
Drug monitoring systems can help track opioid prescription activity to mitigate the opioid crisis. Highlighting the value of these state-sponsored programs to reduce overprescribing, this report recommends eight practices to optimize the use of prescription drug monitoring programs and review state adoption of them. The strategies include simplifying the prescriber enrollment process and integrating health information technology.
Horsham, PA: Institute for Safe Medication Practices; 2016.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety.
Martin L, Laderman M, Hyatt J, Krueger J. Cambridge, MA: Institute for Healthcare Improvement; April 2016.
Addressing the Global Shortages of Medicines, and the Safety and Accessibility of Children's Medication.
Geneva, Switzerland: World Health Organization; 2015.
Drug shortages have the ability to affect the patient safety in emergency departments, oncology services, and pediatrics. This report discusses the consequences of drug shortages, approaches different countries are taking to reduce their occurrence, and strategies such as proactive identification of potential supply limitations and collective agreements to manage shortages.
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.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2015. Report No. OEI-01-13-00400.
A widely-reported meningitis outbreak in the United States uncovered quality and safety issues associated with the use of compounded sterile preparations. This publication describes an analysis of five accreditation organizations and their ability to provide oversight and inspection of Medicare hospitals that contract with compounding entities. The authors offer recommendations to help hospitals determine if their compounded sterile preparations contracts ensure products are prepared safely for use, including targeted training for surveyors related to compounding and improved contracting processes.
NCPDP Recommendations and Guidance for Standardizing the Dosing Designations on Prescription Container Labels of Oral Liquid Medications Version 1.0.
Scottsdale, AZ: National Council for Prescription Drug Programs; March 2014.
This white paper describes recommendations to reduce risks around oral liquid medication administration, including assigning a standard unit of measure (milliliters), using leading zeroes before decimal points (for amounts smaller than one), and ensuring that dosing mechanisms and container labels employ corresponding units of measure.
Rockville, MD: Agency for Healthcare Research and Quality; August 2013. AHRQ Publication No. 13-0067-EF.
This report summarizes findings from projects that explored how health information technology can augment quality and safety in ambulatory care.
Horsham, PA: Institute for Safe Medication Practices; 2013.
London, UK: All-Party Pharmacy Group; May 2012.
This report discusses the impact of drug shortages in the United Kingdom and describes potential solutions.
Silver Spring, MD: US Food and Drug Administration; October 31, 2011.
This report outlines the complex nature of drug shortages and suggests strategies to augment the FDA's efforts to address them.
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.
This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.
Oakbrook Terrace, IL: Joint Commission Resources and the American Society of Health-System Pharmacists; 2009. ISBN: 9781599403090.
This book provides background on the medication reconciliation process and tips for its application, along with sample forms, checklists, and case studies.