Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
Education and Training
- Students 1
- Error Reporting and Analysis 3
- Human Factors Engineering 3
- Legal and Policy Approaches 8
- Logistical Approaches 1
- Quality Improvement Strategies 5
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 4
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events
- Psychological and Social Complications 1
- Surgical Complications 3
Search results for "Medication Safety"
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Journal Article > Commentary
Litman RS. J Patient Saf Risk Manag. 2019 Feb 5; [Epub ahead of print].
This commentary explores how gaps in legal and regulatory structure affect anesthesia medication safety. The author advocates for use of a public health law framework to prevent certain types of perioperative medication errors made by anesthesiologists. Policy approaches that require organizations to provide prefilled syringes and barcoding scanners are suggested to avoid vial- and syringe-related mistakes.
Journal Article > Study
Shiffman S, Cotton H, Jessurun C, Rohay JM, Sembower MA. J Am Pharm Assoc (2003). 2016;56:495-503.
Poor health literacy is associated with the misunderstanding of medication labels, which can lead to adverse drug events. This study sought to assess how adding an acetaminophen icon to the labels of acetaminophen-containing medications affects consumers' ability to avoid unintentional overdose, which is known to cause liver damage. Investigators found that presence of the icon reduced the likelihood of medication errors by 53%, and they concluded that the icon may particularly benefit those with lower health literacy. A past WebM&M commentary discussed a case of liver injury caused by incorrect dosing of acetaminophen.
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.
ISMP Medication Safety Alert! Acute Care Edition. January 13, 2011;16:1-4.
This article reports results from a survey on the Centers for Medicare & Medicaid Services "30-minute rule" and provides a set of revised guidelines.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Journal Article > Study
Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008;118:1928-1930.
This survey revealed that many otolaryngologists have witnessed medication errors due to incorrect administration of concentrated epinephrine during surgery.
Journal Article > Study
Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Ann Intern Med. 2008;149:29-32.
Efforts to improve the quality and safety of care are being driven in part by a growing focus on public reporting. This commentary shares the potential for the unintended consequences of reporting on flawed performance measures, using time to first antibiotic dose (TFAD) in patients with pneumonia as an example. The authors discuss the background data for this particular quality measure, how it was translated into a performance standard, and the response it generated from emergency departments as well as payers, regulators, and professional societies. The authors conclude with a number of lessons learned from this case example, including the tension that results from having providers balance their desire to do the right thing with the public's view of their quality of care when they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card on such measures.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.
This article reports on criminal charges brought against a nurse after she committed a medication error.
Wahlberg D. Wisconsin State Journal. July 22, 2006:A1.
This article reports on a federal warning issued to a hospital after a medication error led to the death of a 16-year-old girl.
Cases & Commentaries
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Legislation/Regulation > Government Resource
US Food and Drug Administration, HHS. Final rule. Fed Regist. February 26, 2004;69(38):9119-9171.
The US Food and Drug Administration (FDA) requires certain human drug and biological product labels to contain bar codes. The rule aims to reduce the number of medication errors by allowing health care professionals to use bar code scanning equipment for necessary verification. This protects against an incorrect drug administration. Effective date: April 26, 2004.