Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 4
- Education and Training 8
- Error Reporting and Analysis 11
- Human Factors Engineering 6
- Legal and Policy Approaches 6
- Quality Improvement Strategies 9
- Teamwork 1
- Technologic Approaches 3
- Transparency and Accountability 3
- Device-related Complications 1
- Identification Errors 2
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 7
- Overtreatment 2
- Psychological and Social Complications 1
- Surgical Complications 1
Search results for "Specific to High-Risk Drugs"
- Specific to High-Risk Drugs
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014.
This national action plan aims to align the efforts of multiple federal programs committed to reducing patient harms related to adverse drug events. The three initial high-priority targets of the action plan are anticoagulants, diabetes agents, and opioids. These medication classes were chosen due to their common usage and their very high potential to cause clinically significant, preventable, and measurable adverse events. The action plan outlines a four-pronged approach: surveillance, prevention, incentives and oversight, and research. The full report delves into detailed tactics for each of these areas, as well as for the three drug classes. Focusing on specific high-risk drug classes, rather than pursuing the commonly advocated approach of universal drug safety, was also recommended by a recent systematic review of medication errors.
Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2019. ISBN: 978926474260.
The overprescribing of prescription opioids heightens the likelihood of opioid dependence and harm. This report shares data from 25 countries to provide a baseline for the current crisis. The publication illustrates the complexity of the opioid epidemic and suggests that system-focused multisector strategies are required to address the problem.
Boston, MA: Institute for Healthcare Improvement; 2019.
Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.
Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015.
Weiss AJ, Heslin KC, Barrett ML, Izar R, Bierman IR. HCUP Statistical Brief #244. Rockville, MD: Agency for Healthcare Research and Quality; September 2018.
Polypharmacy, chronic conditions, and mental health needs can contribute to misuse of opioids. This data analysis from the AHRQ Healthcare Cost and Utilization Project found that opioid-related hospitalizations and emergency room visits for older Americans increased substantially between 2010 and 2015.
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.
Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380.
Ineffectively prescribed opioids contribute to opioid misuse and overdose among patients. This report analyzed activities at five Veterans Health Administration facilities and found inconsistent application of opioid safety strategies in the system. System-level recommendations to enhance practice include cross-system tracking efforts with defined goals and establishing a pain management leadership role at each facility.
The STOP Measure. Safe and Transparent Opioid Prescribing to Promote Patient Safety and Reduced Risk of Opioid Misuse.
Washington, DC: America's Health Insurance Plans; 2018.
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.
Washington, DC: United States Government Accountability Office; October 2017. Publication GAO-18-15.
Opioid prescribing is under increased scrutiny in an effort to address opioid misuse. Examining Medicare Part D prescription trends, this report recommends that the Centers for Medicare and Medicaid Services collect more data on beneficiaries receiving high doses of opioids and the clinicians who prescribe them and advocates for increased reporting of clinicians who inappropriately prescribe opioids. An Annual Perspective discussed the opioid epidemic as a patient safety problem.
Adams SM, Blanco C, Chaudhry HJ, et al. Washington, DC: National Academy of Medicine; 2017.
Morbidity and mortality from opioid medications constitutes a patient safety problem. This National Academy of Medicine report explores the role of physicians in preventing and treating opioid misuse. The report highlights the increasing rate of opioid prescriptions in parallel with rising numbers of opioid overdose deaths and recommends adherence to clinical guidelines on opioid use, specifically the 2016 CDC guideline. The authors call for improved access to opioid prescription and dispensing data and more stringent regulation of opioid medications. They provide detailed recommendations for clinicians to prescribe opioids more safely, including the use of prescription drug monitoring programs, coprescription of naloxone, and engaging with community resources to identify and treat opioid use disorder. A recent PSNet perspective discussed opioid overdoses as a patient safety problem.
Schnell M, Currie J. Cambridge, MA: National Bureau of Economic Research; August 2017. Working Paper No. 23645.
Overprescribing is seen as a contributor to the current opioid epidemic. This working paper explores the potential role that physician education and medical school quality have on prescribing behaviors. Analyzing data from 2006–2014, the authors found that lower ranked institutions wrote more opioid prescriptions and conclude that physician education may be a logical focus of improvement efforts. A recent PSNet perspective explored opioid overdose as a patient safety problem.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; July 2017. Report No. OEI-02-17-00250.
Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use.
Bonnie RJ, Ford MA, Pillips JK, eds. Washington, DC: National Academies Press; 2017.
Addressing the opioid epidemic will require a complex set of approaches to balance managing the potential for harms associated with opioid prescribing with ensuring effective pain management. This report from a consensus project explores the overarching issues associated with the opioid epidemic and outlines recommendations to improve opioid safety, including a heightened focus on public health solutions and enhanced patient management. A recent PSNet perspective discussed opioid overdose as a patient safety problem.
Weiner J, Bao Y, Meisel Z. LDI/CHERISH Issue Brief. June 2017.
Health care has been exploring a variety of strategies to mitigate the opioid epidemic. Exploring the current state of prescription drug monitoring programs as one approach to reduce the misuse of prescribed opioids, this issue brief discusses the role of provider and patient behaviors, the potential for mandates to increase monitoring, and integration of monitoring systems into electronic health record technologies as avenues to support improvement.
Horsham, PA: Institute for Safe Medication Practices; May 2017.
Insulin is a widely used medication that can contribute to serious patient harm if used incorrectly. This report provides information about problems associated with insulin use in adults and offers consensus-developed strategies to encourage subcutaneous insulin practices that reduce errors at the prescribing, pharmacy management, administration, and transition phases.
Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy and Management at Brandeis University; 2016.
Drug monitoring systems can help track opioid prescription activity to mitigate the opioid crisis. Highlighting the value of these state-sponsored programs to reduce overprescribing, this report recommends eight practices to optimize the use of prescription drug monitoring programs and review state adoption of them. The strategies include simplifying the prescriber enrollment process and integrating health information technology.
Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. HCUP Statistical Brief #219. Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
Opioids are known to be high-risk medications, and their misuse is an increasingly recognized patient safety problem. This data analysis from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project delineates trends in opioid-related hospitalizations by state between 2005 and 2014. Both hospital stays and emergency department visits related to opioids have been increasing every year, paralleling trends in opioid overdose deaths. There was substantial variation across states, and the overall rate of opioid-related inpatient stays was 225 per 100,000 population for 2014. These data underscore the need to improve the safety of opioid use to prevent morbidity and mortality.
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.
Forstag EH; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Health and Medicine Division. Washington, DC: National Academy of Science; 2016. ISBN: 9780309451901.
Efforts to ensure safe pain management in the context of the opioid epidemic have focused on prescribing behaviors and policies. This publication reports on the results of a workshop convened to explore factors that contribute to opioid overuse and to identify areas for improvement that require further research.
Martin L, Laderman M, Hyatt J, Krueger J. Cambridge, MA: Institute for Healthcare Improvement; April 2016.
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.