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- Communication Improvement 4
- Culture of Safety 2
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- Error Reporting and Analysis 1
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- Specialization of Care 1
- Technologic Approaches 2
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.
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.
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.
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.
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.
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; 2007. ISBN: 9781599400976.
Co-authored by a host of medication safety experts, this book offers practical information, case studies, and systems-oriented strategies for medication error prevention.
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.
Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.
Casey MM, Moscovice I, Davidson G. Upper Midwest Rural Health Research Center; December 2005.
The authors report the findings of a national study of small, rural hospitals in the United States. Results indicate a relationship between accreditation by the Joint Commission on Accreditation of Healthcare Organizations, financial status, pharmacy staffing, and technology use with the implementation of medication safety practices.
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.
Leape LL, Kabcenell A, Berwick DM, Roessner J. Boston, MA: Institute for Healthcare Improvement; 1998.
This application-oriented book provides the results of the Institute for Healthcare Improvement (IHI) Breakthrough Series program focusing on decreasing adverse drug events in health care facilities. More than 40 organizations share their collective learning experience, from planning for improvement, testing ideas, studying what they learned, and implementing change. The book’s numerous case studies, descriptions of step-wise improvement processes, and strategies for breaking down organizational barriers help illustrate the experience and methods that led to the group’s success. The book will be valuable to individuals and institutions attacking the problem of medication errors or seeking insight into collaborative learning models.