Narrow Results Clear All
- WebM&M Cases 15
- Perspectives on Safety 4
- Commentary 18
- Review 6
- Study 33
- Audiovisual 5
- Book/Report 12
- Legislation/Regulation 4
- Newspaper/Magazine Article 21
- Special or Theme Issue 7
- Toolkit 4
- Web Resource 8
- Grant 1
- Meeting/Conference 2
- Press Release/Announcement 3
- Communication between Providers 29
- Culture of Safety 23
Education and Training
- Students 5
- Error Reporting and Analysis 22
- Human Factors Engineering 29
- Legal and Policy Approaches 15
- Logistical Approaches 7
- Policies and Operations 1
Quality Improvement Strategies
- Reminders 10
- Research Directions 2
- Specialization of Care 10
- Teamwork 7
- Clinical Information Systems 15
- Device-related Complications 12
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems 20
- Drug shortages 1
- Fatigue and Sleep Deprivation 5
- Identification Errors 1
- Medical Complications 15
- Medication Errors/Preventable Adverse Drug Events 83
- Nonsurgical Procedural Complications 7
- Psychological and Social Complications 1
- Surgical Complications 7
- Transfusion Complications 1
- Internal Medicine 45
- Nursing 18
- Pharmacy 42
- Family Members and Caregivers 2
- Health Care Executives and Administrators 97
Health Care Providers
- Nurses 24
- Pharmacists 17
- Physicians 23
Non-Health Care Professionals
- Educators 21
- Media 1
- Patients 12
- Asia 1
- Australia and New Zealand 1
- Europe 20
- Canada 6
Search results for "Education and Training"
Legislation/Regulation > Organizational Policy/Guidelines
Dolan SA, Arias KM, Felizardo G, et al. Washington, DC: Association for Professionals in Infection Control and Epidemiology; February 2016.
Improper injection practices associated with point-of-care testing and treatment can contribute to the spread of health care–associated infections. This position paper outlines how clinicians and infection preventionists can reduce unsafe behaviors with surveillance, oversight, enforcement, individual skills development, and professional accountability.
Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
Opioids are high-risk medications that are increasingly problematic for patients and providers. This guide provides instructions to help hospitals implement initiatives to improve safe prescribing and administration of opioids. Highlighted recommendations include strategies to assess processes, identify best practices, and engage staff to reduce adverse events involving opioids.
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.
ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.
This article discusses incidents involving misadministration of IV insulin and makes recommendations to improve safety in delivering this high-alert medication.
Cases & Commentaries
- Spotlight Case
- Web M&M
Eric S. Holmboe, MD; February 2011
A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.
Journal Article > Study
Thomas AN, Boxall EM, Laha SK, Day AJ, Grundy D. Qual Saf Health Care. 2008;17:360-363.
This study developed and implemented an educational program that provided prescribing standards, formal education, and repeated feedback to reduce errors in practice.
ISMP Medication Safety Alert! Acute Care Edition. May 8, 2008;13:1-3.
This article describes common problems associated with insulin pen injectors and provides recommendations for their safe use.
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.
Tools/Toolkit > Multi-use Website
Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine.
This Web site provides information on the multidisciplinary safety team at Johns Hopkins University, including research projects, presentations, and useful tools for patients, families, and practitioners.
Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.
Journal Article > Review
Tsilimingras D, Rosen AK, Berlowitz DR. J Gerontol A Biol Sci Med Sci. 2003;58:M813-M819.
Cases & Commentaries
- Web M&M
Elise Orvedal Leiten, MD, and Rune Nielsen, MD, PhD; January 2019
Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline. This high dose of midazolam led to the respiratory failure requiring intubation. On top of that, instead of normal saline, lidocaine had been used for the lung lavage.
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.
Journal Article > Study
A quality initiative: a system-wide reduction in serious medication events through targeted simulation training.
Hebbar KB, Colman N, Williams L, et al. Simul Healthc. 2018;13:324-330.
Medication administration errors are common and costly, especially for children. Investigators conducted a multipronged quality improvement intervention for pediatric medication administration. First, they implemented a one-time simulation training for pediatric bedside nurses across emergency department, hospital ward, and intensive care settings to foster use of standardized medication administration best practices. They observed bedside nursing via audits for 18 months of follow-up. Adherence to best practices improved from 51% of medication administration instances to 84%, and the rate of medication administration errors declined significantly. The authors suggest that simulation training is an effective strategy to improve the safety of pediatric medication administration.
Journal Article > Study
Darnall BD, Ziadni MS, Stieg RL, Mackey IG, Kao MC, Flood P. JAMA Intern Med. 2018;178:707-708.
This prospective cohort study found that many outpatients treated at a chronic pain clinic were willing to voluntarily taper opioid medications. Although nearly 40% of patients dropped out of the study, those that remained significantly reduced their opioid dosing. The authors suggest that offering a voluntary gradual opioid taper to patients with chronic pain may reduce their opioid dose.
Chicago, IL: American Hospital Association; 2017.
The opioid epidemic is a challenge to patient safety and public health. This report reviews tools to help health care systems target eight areas of focus that have potential to reduce the impact of opioid misuse, including improving prescribing practices, collaborating with communities, and educating patients.
Journal Article > Review
Parand A, Garfield S, Vincent C, Franklin BD. PLoS One. 2016;11:e0167204.
Medication administration errors have been studied primarily in the hospital environment. Less is known about the types of errors that may occur in the home setting and the role caregivers play in this context. This narrative systematic review found caregiver medication administration error rates ranging from 1.9% to 33% of all medications administered, highlighting a potential threat to patient safety.
Journal Article > Commentary
Farmer BM. Emerg Med. 2016;48:396-404.
Emergency departments are high-risk environments due to the urgency of care needs and complexity of communication. This commentary explores challenges associated with medication administration, handoffs, discharge processes, and electronic health records in emergency medicine and recommends strategies to reduce risks.
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
Benchmarks tracking a wide spectrum of care activities enable comparison that can drive organizational commitment to improving safety. This newsletter article examines survey responses from nearly 400 hospitals which demonstrated modest progress in implementation of medication safety best practices that recommended strategies to augment safety, such as utilizing metric units as the only scale of measure for patient weight.
ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
This newsletter article describes an incident involving a patient who noticed that the tablets in her prescription refill had a different marking than usual, alerting her that she might have received an incorrect medication which was confirmed by the pharmacist. Tips for patients to avoid medication errors include being familiar with how their medicines look and checking prescriptions before leaving the pharmacy. Practitioners can help prevent these errors by counting and labeling prescriptions one at a time and performing patient consultations.