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Search results for "State Governments and Agencies"
- Noncognitive Errors ("Slips & Lapses")
- State Governments and Agencies
Journal Article > Study
Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.
Web Resource > Multi-use Website
Michigan Pharmacists Association.
Gao T, Gaunt MJ. PA-PSRS Patient Saf Advis. December 2013;10:125-136.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies problems related to the medication reconciliation process and includes methods to address them.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
Special or Theme Issue
FIRST Do No Harm. December 2012;1-8.
This newsletter issue highlights initiatives and tools developed to improve handoff communication in Massachusetts.
PA-PSRS Patient Saf Advis. June 2005;2:19-21.
This advisory from the Pennsylvania Patient Safety Reporting System discusses 125 reports of tourniquets being inappropriately left on patients and provides strategies to reduce these occurrences.