Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "United States of America"

1 - 20 of 2204 results
Download Selected Citations

Show: 20 | 50 | 100

Audiovisual > Audiovisual Presentation

Medication Safety Practitioners: Leading, Innovating, and Improving Healthcare.

Institute for Safe Medication Practices. October 5, 2017; 1:30–3:00 PM (Eastern).

Medication safety officers focus on improving medication safety in their institutions. In this webinar, two medication safety officers will describe their role in reducing medication errors, investigating events, strategic planning, and establishing a culture of safety.

Meeting/Conference > New Jersey Meeting/Conference

ISMP Medication Safety Intensive.

Institute for Safe Medication Practices. September 21-22, 2017, Maggiano's Little Italy Hackensack, Hackensack, NJ.

This workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Audiovisual > Audiovisual Presentation

2017 Update on The Joint Commission Medication-Related Standards.

Institute for Safe Medication Practices. July 27, 2017; 1:30–3:00 PM (Eastern).

This webinar will explore common challenges to achieving Joint Commission accreditation standards and safety goals associated with medication delivery and discuss strategies to increase compliance with the standards and goals.

Newspaper/Magazine Article

Death due to pharmacy compounding error reinforces need for safety focus.

ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.

Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.

Journal Article > Review

Interventions to improve oral chemotherapy safety and quality: a systematic review.

Zerillo JA, Goldenberg BA, Kotecha RR, Tewari AK, Jacobson JO, Krzyzanowska MK. JAMA Oncol. 2017 Jun 1; [Epub ahead of print].

This systematic review of quality and safety practices for oral chemotherapy found that telephone calls from nurses identified adverse medication events and supported adherence. Technology-enabled approaches such as text messaging, interactive voice response, and video-observed therapy have not been effective to date.

Audiovisual > Audiovisual Presentation

Medication Safety Certificate Program.

American Society of Health-System Pharmacists and Institute for Safe Medication Practices.

Leadership commitment to reduce medication errors can help address this safety problem. This certificate program presents key concepts that support organizational efforts to augment medication safety, including event analysis, safety culture, risk identification, and change management.

Book/Report

Communicating Clearly About Medicines: Proceedings of a Workshop—in Brief.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2017.

Medication safety is a global health care concern. This workshop proceedings report highlights expert opinion on how to improve the clarity of medication information and the way it is communicated to patients. Panelists focused on elements of the process such as the patient experience, health literacy, medication instructions, and design of medication packaging.

Book/Report

ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults.

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.

Press Release/Announcement

ISMP International Safe Medication Management Fellowship.

Institute for Safe Medication Practices.

This fellowship program with the Institute for Safe Medication Practices is a 2-year appointment for clinicians who seek to gain experience with global efforts to improve the safety of medication delivery. The deadline to apply for consideration is June 30, 2017.

Journal Article > Study

Postoperative opioid prescribing and the pain scores on Hospital Consumer Assessment of Healthcare Providers and Systems survey.

Lee JS, Hu HM, Brummett CM, et al. JAMA. 2017;317:2013-2015.

The opioid crisis is one of the nation's most pressing patient safety problems. Concern has been raised that overprescribing of opioids may be an unintended consequence of efforts to improve patient satisfaction. However, this Michigan study found no relationship between postoperative opioid prescribing and patient satisfaction scores, indicating that efforts to reduce opioid prescribing may not adversely affect patient satisfaction.

Journal Article > Study

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017 May 1; [Epub ahead of print].

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

Journal Article > Study

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

Harris LM, Dreyer BP, Mendelsohn AL, et al. Acad Pediatr. 2017;17:403-410.

Correctly dosing liquid medications for children can be challenging for caregivers with limited health literacy. This cross-sectional analysis found that parents with limited English proficiency and health literacy were more likely to make dosing errors with liquid medications. These results affirm the need to redesign medication labels and dosing aids to promote safe use.

Special or Theme Issue

Polypharmacy.

Zagaria MAE, ed. Clin Geriatr Med. 2017;33:153-292.

Older patients are likely to be prescribed multiple medications, which can increase risks. Articles in this special issue explore polypharmacy in a variety of care settings and provide tactics for improvement, such as enhancing care integration for older patients through medication reconciliation and deprescribing initiatives.

Web Resource > Multi-use Website

Medication Without Harm: WHO's Third Global Patient Safety Challenge.

Geneva, Switzerland: World Health Association.

Adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients. This website provides information about a worldwide effort to improve medication safety by examining elements of medication prescription, distribution, and use that are vulnerable. The campaign will highlight best practices to address these weaknesses.

Journal Article > Commentary

Polypharmacy in the elderly—when good drugs lead to bad outcomes: a teachable moment.

Carroll C, Hassanin A. JAMA Intern Med. 2017 Apr 24; [Epub ahead of print].

Geriatric patients are particularly vulnerable to adverse drug events due to comorbidities, complicated care plans, and polypharmacy. This commentary describes how using STOPP criteria and performing indication mapping can help reduce polypharmacy and improve patient safety.

Journal Article > Study

Root cause analysis of adverse events in an outpatient anticoagulation management consortium.

Graves CM, Haymart B, Kline-Rogers E, et al. Jt Comm J Qual Patient Saf. 2017;43:299-307.

Anticoagulation confers a high risk of adverse drug events. Examining root cause analyses of anticoagulation–related adverse events, this study found that the majority were not preventable and were due to patient-specific issues. Unlike a prior study, researchers did not include patient perspectives in their analysis, which may have affected their conclusions.

Journal Article > Study

New persistent opioid use after minor and major surgical procedures in US adults.

  • Classic

Brummett CM, Waljee JF, Goesling J, et al. JAMA Surg. 2017 Apr 12; [Epub ahead of print].

Opioid medication use represents a significant safety problem in the United States. Overprescribing by providers is one factor contributing to the widespread use of opioids. Reducing inappropriate prescribing may help improve patient safety. Using claims data for 36,177 patients, investigators sought to better characterize new and persistent opioid use after surgery, defined as filling an opioid prescription between 90 and 180 days postoperatively. Although there was no major difference in persistent opioid use between those who underwent minor surgical procedures and those who underwent major surgical procedures, results demonstrated that opioid use persisted in greater frequency after surgery among patients with behavioral, pain, and substance use disorders. A recent PSNet perspective discussed patient safety with regard to opioid medications.

Newspaper/Magazine Article

The opioid crisis: can improving diagnosis help solve the problem?

Carr S. ImproveDx. April 2017;4:1-4.

The opioid epidemic has been widely discussed, but little research has examined how misdiagnosis can contribute to the problem. This newsletter article suggests that addressing bias, improving diagnosis, and providing pain management training for primary care providers could augment opioid safety.

Journal Article > Study

Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care.

Sharma M, Krishnamurthy M, Snyder R, Mauro J. Clin Pract. 2017;7:953.

Anticoagulants are considered high-risk medications due to their narrow therapeutic window and association with adverse drug events. This study suggests that integration of a clinical pharmacist into the inpatient team may help prevent anticoagulation dosing errors and resultant harm to patients.

Journal Article > Study

Analysis of variations in the display of drug names in computerized prescriber-order-entry systems.

Quist AJL, Hickman TT, Amato MG, et al. Am J Health Syst Pharm. 2017;74:499-509.

Evidence suggests that computerized provider order entry (CPOE) systems improve medication safety by mitigating prescribing errors. However, CPOE systems may contribute to errors when user-centered design is not taken into account. In this study, researchers standardized the assessment of 10 distinct inpatient and ambulatory CPOE systems across 6 health care institutions to determine how variation in drug name display may increase the risk of medication errors. Using test patient scenarios, they found significant variation in drug name display, including inconsistencies with regard to the display of brand and generic names. Providers could theoretically prescribe both the brand and generic drug, increasing the risk for patient harm. A recent Annual Perspective discussed the benefits and limitations of CPOE with regard to patient safety.

Back to Top