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- Perspectives on Safety 1
- Study 2
- Audiovisual 6
- Book/Report 1
- Newspaper/Magazine Article 28
- Special or Theme Issue 2
- Toolkit 1
- Web Resource 17
- Press Release/Announcement 16
- Communication Improvement 10
- Culture of Safety 2
- Education and Training 19
- Error Reporting and Analysis 12
- Human Factors Engineering 11
- Legal and Policy Approaches 10
- Policies and Operations 1
- Quality Improvement Strategies 17
- Research Directions 1
- Teamwork 1
- Technologic Approaches 8
- Device-related Complications 3
- Discontinuities, Gaps, and Hand-Off Problems 1
- Drug shortages 1
- Identification Errors 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 31
- Nonsurgical Procedural Complications 1
- Surgical Complications 2
- Internal Medicine 13
- Nursing 2
- Pharmacy 25
- Family Members and Caregivers 3
- Health Care Executives and Administrators 18
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 2
- Europe 2
- Canada 1
Search results for "Patients"
- Specific to High-Risk Drugs
Tools/Toolkit > Fact Sheet/FAQs
Horsham, PA: Institute for Safe Medication Practices; 2018.
This set of leaflets provides patients with information about taking high-alert medications safely.
Web Resource > Government Resource
Centers for Disease Control and Prevention.
Landro L. Wall Street Journal. March 5, 2008:D1.
This article reports on new policies and procedures adopted by hospitals to prevent errors in the use of high-alert medications, such as heparin.
Brody JE. New York Times. January 2, 2007:F7.
This article discusses some common medication errors that consumers can avoid by asking the right questions and being familiar with prescriptions and the proper directions for taking them.
Chun D. Gainsville Sun. August 21, 2006.
This article describes a computerized drug ordering and dispensing system at a Florida hospital.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.
This column chronicles the tragic death of Betsy Lehman, a Boston Globe health columnist, who fell victim to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute. The story details the events surrounding the case, the reactions among family and the public, and the response from Dana-Farber.
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Journal Article > Study
Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS. Science. 2018;361:1184.
Opioid overdose deaths remain a threat to patient safety. Information about how overdose deaths are nationally distributed is critical to inform prevention efforts. This robust analysis examined all drug overdose deaths in the United States over a 38-year period. Drug overdoses began increasing exponentially long before the opioid prescribing boom in the mid-1990s and continue to rise in this way. Demographically distinct subepidemics of prescription opioid, synthetic opioid, and stimulant use all contribute to drug overdose deaths as a whole. The authors speculate about what factors other than opioid prescribing might drive escalating substance use-related deaths. An Annual Perspective and a PSNet perspective provide further insights into how safety efforts can reduce opioid-related harm.
Daley J. Colorado Public Radio. February 23, 2018.
Innovations in the prescribing of opioids in the emergency department are needed to change practice and help address the opioid crisis. This news article reports the results of a 10-hospital pilot program, the Colorado Opioid Safety Collaborative, which used alternative pain control approaches to reduce opioid prescriptions by an average of 36%. The program builds on multidisciplinary teamwork to modify pain management in the emergency department. An Annual Perspective highlighted opioid misuse as a patient safety challenge.
Special or Theme Issue
Benzon HT, Anderson TA, eds. Anesth Analg. 2017;125:1427-1778.
Anesthesiologists provide pain management services in both perioperative and inpatient settings. Articles in this special issue review factors that contribute to the opioid epidemic and how anesthesiologists have a role in developing solutions. Topics covered include prescription monitoring, cancer care, and medicolegal concerns of pain medication management.
Tools/Toolkit > Government Resource
Centers for Disease Control and Prevention.
The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to raise awareness of the addictive nature of the medication. This national campaign enlists communities and individual clinicians to provide patient education to address the opioid epidemic. The website offers videos and other resources to assist community-level efforts to reduce risk for opioid addiction.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. October 12, 2017.
Care devices that enable patients to administer medicines at home can have unintended consequences. This alert raises awareness of hazards related to insulin pen misuse and offers recommendations to reduce risks, such as training patients to properly use pen needles and engaging community pharmacists in verifying that patients understand appropriate administration techniques.
William Brangham. PBS News Hour. September 29, 2017.
Hoffman J. New York Times. June 10, 2016.
Overprescribing of opioids for pain management contributes to the growing crisis involving opioid-related harm. This newspaper article reports on one hospital's efforts to avoid opioid use for patients presenting to the emergency department with pain. Alternative treatments included nonnarcotic infusions, nitrous oxide, music therapy, and holistic techniques.
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.
Ornstein C. Washington Post. July 12, 2015.
Anticoagulants are considered high-alert medications that if used ineffectively can result in patient harm. Reporting on an anticoagulant commonly used in nursing homes and patient harm linked to this medication, this newspaper article relates reasons doctors are reluctant to prescribe new drugs to older patients and challenges to monitoring and preventing such adverse drug events.