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- Error Reporting and Analysis
- Legal and Policy Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches 1
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- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 4
- Psychological and Social Complications 1
Search results for "Physicians"
Journal Article > Commentary
Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic.
Beauchamp GA, Winstanley EL, Ryan SA, Lyons MS. Am J Public Health. 2014;104:2023-2029.
A substantial number of drug deaths in the United States have been associated with inadvertent overdose of prescription opioids. This commentary explores contributors to iatrogenic opioid addiction, identifies patient characteristics that increase risk of drug dependence, and makes recommendations for education and research to improve safety of chronic pain management.
Tools/Toolkit > Measurement Tool/Indicator
Horsham, PA: Institute for Safe Medication Practices.
This reporting program collects data on errors and concerns associated with vaccines.
Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study.
Avery T, Barber N, Ghaleb M, et al. London, UK: General Medical Council; May 2, 2012.
Examining prescription errors in general practices in England, this report suggests that information technology and incident reporting could address issues that persist since an earlier study.
Journal Article > Study
Which clinical errors lead to the referral of UK paediatricians to the National Clinical Assessment Service?
Raine J, Scarrott D. Eur J Pediatr. 2012;171:1449-1452.
This study discovered that child protection cases and prescribing errors were the most common reasons pediatricians were referred to a governing body overseeing provider performance concerns.
Journal Article > Study
Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Ann Intern Med. 2008;149:29-32.
Efforts to improve the quality and safety of care are being driven in part by a growing focus on public reporting. This commentary shares the potential for the unintended consequences of reporting on flawed performance measures, using time to first antibiotic dose (TFAD) in patients with pneumonia as an example. The authors discuss the background data for this particular quality measure, how it was translated into a performance standard, and the response it generated from emergency departments as well as payers, regulators, and professional societies. The authors conclude with a number of lessons learned from this case example, including the tension that results from having providers balance their desire to do the right thing with the public's view of their quality of care when they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card on such measures.
Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.