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- Communication between Providers 39
- Culture of Safety 6
Education and Training
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- Logistical Approaches 16
- Policies and Operations 3
- Quality Improvement Strategies 44
- Specialization of Care 15
- Teamwork 1
- Clinical Information Systems 32
- Alert fatigue 1
- Device-related Complications 9
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 15
- Drug shortages 10
- Identification Errors 2
- Interruptions and distractions 1
- Medical Complications 8
- Medication Errors/Preventable Adverse Drug Events 131
- Surgical Complications 2
- Allied Health Services 1
- Internal Medicine 32
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- Nursing 21
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- Health Care Executives and Administrators 86
Health Care Providers
- Nurses 22
- Pharmacists 83
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Non-Health Care Professionals
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- Patients 49
Search results for "Pharmacy"
- Newspaper/Magazine Article
Santell JP. Drug Topics (Health-System Edition). May 22, 2006.
This article reports on errors involving neuromuscular blocking agents (NMBAs) that were reported to Medmarx database, what factors contributed to those errors, and what can be done to minimize their occurrence.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6.
Look-alike and sound-alike medications present a recurring threat to patient safety. This newsletter article summarizes an analysis of reported drug name confusion errors. Although incidents seem to have decreased over time, the influx of generic drug names is contributing to the persistence of the problem. Increased federal attention to the issue, provider use of known strategies to improve practice, and pharmaceutical company testing of names to avoid similarities can help reduce drug name confusion.
Wild D. Pharmacy Practice News. November 8, 2018.
Medication safety officers serve as organizational champions of medication management process improvement. This news article offers two examples of health care organizations that positioned medication safety officers as leaders in their systems. The piece describes improvements stemming from employment of medication safety officers at these organizations.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Peeples L. Pharmacy Practice News. October 10, 2018.
Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
Sederstrom J. Drug Topics. September 17, 2018.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.
Decerbo M. Pharmacy Practice News. September 13, 2018.
Parenteral nutrition errors can result in patient malnutrition and harm. Reporting on how insufficient understanding of malnutrition contributes to its presence in health care, this news article suggests that both general guidelines and tailored approaches to nutrition are necessary to keep hospitalized patients safe. Improvements in addressing the complicated needs of patients who are older or have cancer illustrate progress made toward the effective delivery of nutrition.
Pharmacy Practice News. April 4, 2018.
Despite considerable effort, medication errors continue to occur and result in patient harm. Summarizing reports of medication mistakes submitted to the Institute for Safe Medication Practices for analysis, this news article describes types of problems, prevention strategies, and technologies that can reduce risks.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.
ISMP Medication Safety Alert! Acute Care Edition. October 19, 2017;22:1-3.
Blank C. Drug Topics. October 13, 2017.
ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.
Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.
Straka M, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. June 2017;14:55-63.
According to this analysis of more than 1000 reports of errors occurring in community pharmacies, more than half reached the patient. Common error types included wrong drug and wrong dose incidents. Counseling patients on their medications at the point of sale can improve the reliability of outpatient pharmacy practice.
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.
ISMP Medication Safety Alert! Acute Care Edition. August 25, 2016;21:1-3.
Reporting the results of a survey on "as directed" instructions for medications and summarizing cases of misunderstandings resulting from the practice, this newsletter article recommends that physicians should provide explicit directions regarding medication administration steps to patients to ensure medications are used safely and pharmacists are able to provide appropriate patient counseling if required.
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4.
Confusion due to look-alike and sound-alike medications are known to contribute to medication errors. Describing errors associated with a certain medication naming convention, this newsletter article offers recommendations to reduce risks related to these drugs, including labeling clarifications, storing medications separately, barcode scanning, and staff education.