Narrow Results Clear All
- Communication Improvement 7
- Culture of Safety 1
- Education and Training 4
- Error Reporting and Analysis 3
- Human Factors Engineering 3
- Legal and Policy Approaches 1
- Quality Improvement Strategies 5
- Specialization of Care 3
- Technologic Approaches 4
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 4
- Drug shortages 2
- Medication Errors/Preventable Adverse Drug Events 6
- Surgical Complications 1
- Australia and New Zealand 1
- Europe 4
- North America 8
Search results for "Pharmacy"
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.
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.
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.
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.
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.
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.
Bethesda, MD: National Council on Patient Information and Education; August 2007.
This report discusses poor medication adherence as a public health issue, describes contributing factors, and outlines a 10-step action plan to improve adherence.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.
Rockville, MD: United States Pharmacopeia; 2007.
This report shares findings from analysis of more than 11,000 perioperative medication errors reported through Medmarx and includes recommendations to avoid these types of errors.
External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.