Narrow Results Clear All
- Slideset 1
- Legislation/Regulation 6
- Special or Theme Issue 1
- Toolkit 2
- Web Resource 49
- Meeting/Conference 5
- Press Release/Announcement 1
- Communication Improvement 41
- Culture of Safety 24
- Education and Training 27
Error Reporting and Analysis
- Error Reporting 22
- Human Factors Engineering 18
- Legal and Policy Approaches 18
- Logistical Approaches 6
- Quality Improvement Strategies 45
- Research Directions 1
- Specialization of Care 7
- Teamwork 4
- Clinical Information Systems 17
- Transparency and Accountability 3
- Device-related Complications 5
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 21
- Drug shortages 7
- Fatigue and Sleep Deprivation 1
- Identification Errors 9
- Medical Complications 25
- Medication Errors/Preventable Adverse Drug Events 65
- Nonsurgical Procedural Complications 5
- Overtreatment 4
- Psychological and Social Complications 3
- Surgical Complications 15
- Transfusion Complications 1
- Allied Health Services 1
- Internal Medicine 26
- Surgery 3
- Nursing 3
- Pharmacy 36
- Health Care Executives and Administrators 108
Health Care Providers
- Nurses 8
- Pharmacists 14
- Physicians 11
Non-Health Care Professionals
- Media 1
- Patients 13
- Australia and New Zealand 5
- Europe 24
- Canada 5
- United States of America 112
Search results for "Medication Safety"
- Medication Safety
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.
CHPSO: Sacramento, CA; 2019.
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their members. This report highlights 2018 trends, activities, and outcomes of initiatives at a 10-state PSO. Sections of the report include high-level review of reported medication and perinatal events, safe table data analysis, and strategies to improve incident reporting.
Horsham, PA: Institute for Safe Medication Practices; January 2019.
Inaccurate or incomplete data in electronic health records can limit the effectiveness of health information technology. This guideline focuses on improvements in how medication information is formatted to support safe medication delivery. Recommended approaches include avoidance of error-prone abbreviations, use of Tall Man lettering, and required use of metric measurements to reduce risks in electronic health records, barcoding systems, smart infusion devices, and other information technologies.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Reducing hospital-acquired conditions (HACs) such as health care-associated infections has been a major focus of quality improvement efforts, motivated in part by Medicare nonpayment and reporting. According to the Agency for Healthcare Research and Quality (AHRQ), HAC rates decreased by just over 20% between 2010 and 2015. In this report, AHRQ estimates that between 2014 and 2016, HAC reduction efforts resulted in an 8% decrease in events, $2.9 billion dollars in savings, and the prevention of about 8,000 deaths. While infections and adverse drug events decreased, pressure ulcers increased and represent an opportunity for further improvement. Overall, this report suggests that HAC reduction efforts continue to be successful.
Rockville, MD: Center for Drug Evaluation and Research, US Food and Drug Administration; April 2016.
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.
Larson CM, Saine D, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2013. ISBN: 9781585282104.
This book provides information about medication errors and quality improvement to guide clinicians involved in medication safety work. Roles and responsibilities of medication safety officers range from change management to error prevention and analysis. The publication also includes checklists and other tools to enhance medication safety.
Vancheri C; Roundtable on Health Literacy; Institute of Medicine. Washington, DC: National Academies Press; 2010. ISBN-10: 0309159318.
This publication summarizes the content delivered at a workshop discussing the FDA's Safe Use Initiative and other medication label improvement programs.
Oak Brook, IL: Joint Commission Resources; 2009. ISBN: 9781599403670.
This guide offers tools and strategies to ensure that care in the ambulatory setting is safely provided, evidence-based, and aligned with Joint Commission requirements.
London, UK: Care Quality Commission; October 2009. CQC-039-500-ESP-102009. ISBN: 9781845622442.
This report analyzed how medication information is shared among UK practices and patients after a hospital stay and found that 81% of general practices thought that patient information given to them from hospitals was incomplete or inaccurate.
Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease.
Cambridge, MA: New England Healthcare Institute; August 12, 2009.
Reynard J, Reynolds J, Stevenson P. Oxford, UK: Oxford University Press; 2009. ISBN: 9780199239931.
This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.
Horsham, PA: Institute for Safe Medication Practices.
This website provides quarterly reports that identify and analyze new risks related to medications and adverse drug events submitted to the Food and Drug Administration (FDA). In the third quarter of 2018, FDA received nearly 331,000 reports about adverse drug events, which represents a 16% decrease. This report focuses on problems reported on three psychoactive medications: gabapentin, pimavanserin, and pregabalin.
Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group Management Association; 2009.
This trio of modules provides ambulatory medical practices with tools to develop teamwork, assess culture and processes, and improve medication safety.
Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275.
This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.
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.
Information Design for Patient Safety: A Guide to the Graphic Design of Medication Packaging. 2nd edition.
London, England: The Helen Hamlyn Research Centre and the National Patient Safety Agency; 2007.
This illustrated report provides guidelines for the packaging of pharmaceuticals along with an information design checklist for minimizing medication error.
Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.
OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.
This report shares successful patient safety strategies employed in Ontario hospitals to address medication safety, patient incident management, infection issues, and administrative process improvements.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; August 2006. Report No. OEI-06-05-00060.
This report shares findings from an inspection of the FDA's National Drug Code Directory, which found that the directory is both incomplete and inaccurate in its listings of marketed prescription medications.
Manasse HR Jr, Thompson KK, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2005. ISBN: 1585280895.
This book provides an in-depth introduction to implementing a medication safety program, focusing on the role of leadership and system-level improvements.