Organizational Policy/Guidelines Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety. Citation Text: Jewell ML, Jewell HL, Singer R, et al. Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety. Aesthetic Plast Surg. 2023;47(3):1234-1238. doi:10.1007/s00266-023-03307-0. Copy Citation Format: DOIGoogle ScholarBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL April 26, 2023 Jewell ML, Jewell HL, Singer R, et al. Aesthetic Plast Surg. 2023;47(3):1234-1238. View more articles from the same authors. Fentanyl is a high-risk medication, whether prescribed by a health professional or obtained illicitly. This patient safety advisory encourages healthcare providers to educate their patients on the risks of counterfeit fentanyl. PubMed citation Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Jewell ML, Jewell HL, Singer R, et al. Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety. Aesthetic Plast Surg. 2023;47(3):1234-1238. doi:10.1007/s00266-023-03307-0. Copy Citation Format: DOIGoogle ScholarBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022 Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting. June 24, 2015 The next organizational challenge: finding and addressing diagnostic error. March 5, 2014 Family safety reporting in medically complex children: parent, staff, and leader perspectives. July 6, 2022 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020 Standardization of inpatient handoff communication. January 18, 2017 Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems. June 18, 2008 Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017 Low rate of completion of recommended tests and referrals in an academic primary care practice with resident trainees. January 31, 2024 Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review. January 12, 2022 Adverse drug events in hospitalized cardiac patients. November 7, 2007 Development of a multicomponent intervention to decrease racial bias among healthcare staff. July 27, 2022 Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. July 17, 2013 Crowding in the Emergency Department: Challenges for the Care of Children. March 15, 2023 Association of postoperative readmissions with surgical quality using a Delphi consensus process to identify relevant diagnosis codes. May 16, 2018 Optimizing Pediatric Patient Safety in the Emergency Care Setting. October 19, 2022 Role of pharmacist counseling in preventing adverse drug events after hospitalization. March 22, 2006 Taking patients' narratives about clinicians from anecdote to science. August 19, 2015 Americans' growing exposure to clinician quality information: insights and implications. March 20, 2019 What words convey: the potential for patient narratives to inform quality improvement. April 24, 2019 The new diagnostic team. November 22, 2017 Implementation of bar-code medication administration to reduce patient harm. February 20, 2019 Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial October 16, 2019 Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes. April 5, 2017 A case for safety leadership team training of hospital managers. March 2, 2011 Design and evaluation of simulation scenarios for a program introducing patient safety, teamwork, safety leadership, and simulation to healthcare leaders and managers. August 31, 2011 An exploration of safety climate in nursing homes. August 8, 2012 Improving patient care through leadership engagement with frontline staff: a Department of Veterans Affairs case study. July 31, 2013 Primary care collaboration to improve diagnosis and screening for colorectal cancer. May 3, 2017 Patient safety climate in 92 US hospitals: differences by work area and discipline. February 4, 2009 Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019. January 4, 2021 Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study. June 7, 2023 A call to action: next steps to advance diagnosis education in the health professions. June 8, 2022 Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. November 21, 2007 Health outcomes associated with potentially inappropriate medication use in older adults. April 2, 2008 Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. July 18, 2012 From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. February 26, 2014 Medication reconciliation in oncological patients: a randomized clinical trial. June 15, 2016 The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. February 10, 2021 Key potentially inappropriate drugs in pediatrics: the KIDs list. June 24, 2020 Use of a novel, modified fishbone diagram to analyze diagnostic errors. July 16, 2014 I-CaRe: a case review tool focused on improving inpatient care. February 4, 2009 Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems. March 8, 2006 FDA drug prescribing warnings: is the black box half empty or half full? December 7, 2005 Development of trigger tools for surveillance of adverse events in ambulatory surgery. November 10, 2010 Applying trigger tools to detect adverse events associated with outpatient surgery. March 16, 2011 Consensus building for development of outpatient adverse drug event triggers. June 15, 2011 High-alert medications in the pediatric intensive care unit. January 7, 2009 Validity of selected AHRQ Patient Safety Indicators based on VA National Surgical Quality Improvement program data. October 15, 2008 Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units. November 6, 2013 Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations. March 15, 2017 Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study. January 17, 2024 Completion of recommended tests and referrals in telehealth vs in-person visits. December 6, 2023 Perceptions of hospital safety climate and incidence of readmission. December 15, 2010 Hospital safety climate and safety outcomes: is there a relationship in the VA? March 10, 2010 Identifying organizational cultures that promote patient safety. November 18, 2009 Comparing safety climate between two populations of hospitals in the United States. October 14, 2009 The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience. May 6, 2009 Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration. March 25, 2009 Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey. September 26, 2007 Recruitment of hospitals for a safety climate study: facilitators and barriers. April 30, 2008 An overview of patient safety climate in the VA. April 9, 2008 National hospital ratings systems share few common scores and may generate confusion instead of clarity. March 11, 2015 Safety in numbers: the development of Leapfrog's composite patient safety score for US hospitals. October 16, 2013 Call to action: addressing pediatric fall safety in ambulatory environments. December 1, 2021 Integrating computerized clinical decision support systems into clinical work: a meta-synthesis of qualitative research. November 4, 2015 Journal Article Study Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers. March 29, 2023 Identifying trigger concepts to screen emergency department visits for diagnostic errors. December 16, 2020 Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? August 25, 2021 Venous thromboembolism after trauma: a never event? October 10, 2012 Bringing diagnosis into the quality and safety equations. October 3, 2012 Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. September 13, 2017 The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program. June 14, 2017 Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. April 22, 2009 The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. February 28, 2007 The evolving literature on safety WalkRounds: emerging themes and practical messages. October 1, 2014 The effectiveness of management-by-walking-around: a randomized field study. April 23, 2014 Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers. May 9, 2018 Use of board certification and recertification of pediatricians in health plan credentialing policies. March 8, 2006 Portable advanced medical simulation for new emergency department testing and orientation. May 10, 2006 Families as partners in hospital error and adverse event surveillance. March 8, 2017 Changes in medical errors after implementation of a handoff program. November 12, 2014 Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018 Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center. August 12, 2020 The I-READI quality and safety framework: a health system’s response to airway complications in mechanically ventilated patients with Covid-19. February 17, 2021 Pediatric musculoskeletal radiographs: anatomy and fractures prone to diagnostic error among emergency physicians. August 3, 2022 Nonopioid directives: unintended consequences in the operating room. June 29, 2022 A multi-method exploratory evaluation of a service designed to improve medication safety for patients with monitored dosage systems following hospital discharge. October 25, 2023 Interventions for improving teamwork in intrapartem care: a systematic review of randomised controlled trials. October 30, 2019 SBAR: electronic handoff tool for noncomplicated procedural patients. January 4, 2012 Preventing harm in the ICU—building a culture of safety and engaging patients and families. July 12, 2017 Differences in the reporting of care-related patient injuries to existing reporting systems. March 6, 2005 Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. May 13, 2009 Real-time automated paging and decision support for critical laboratory abnormalities. August 17, 2011 The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals. February 13, 2013 Improving care transitions: current practice and future opportunities for pharmacists. December 5, 2012 It’s time to consider national culture when designing team training initiatives in healthcare. January 27, 2021 Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis. October 14, 2020 Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: a systematic review and meta-analysis. August 4, 2021 Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review. February 14, 2024 View More Related Resources Sentinel Event Alert 68: updated surgical fire prevention for the 21st Century. November 8, 2023 Systems approach to suicide prevention: strengthening culture, practice, and education. June 28, 2023 Stigmatizing language expressed towards individuals with current or previous OUD who have pain and cancer: a qualitative study. June 14, 2023 Racial inequality in receipt of medications for opioid use disorder. May 31, 2023 Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update. May 17, 2023 How the opioid backlash went wrong. May 17, 2023 Early diagnosis of cancer: systems approach to support clinicians in primary care. April 5, 2023 Crowding in the Emergency Department: Challenges for the Care of Children. March 15, 2023 How should clinicians minimize bias when responding to suspicions about child abuse? February 22, 2023 Advancing diagnostic equity through clinician engagement, community partnerships, and connected care. February 22, 2023 Intended and unintended consequences: changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - controlled and single-series interrupted time series analyses. February 15, 2023 The incidence of opioid misuse among the surgical patients with persistent opioid use. February 8, 2023 ASHP Guidelines on Preventing Diversion of Controlled Substances. December 14, 2022 Rise to Health Coalition. December 14, 2022 How to Stay Safe When Entering the Healthcare System: A Physician Walks across the Country to Raise Awareness of the Need to Improve Healthcare Safety. November 30, 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. November 16, 2022 Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. October 26, 2022 Sixty seconds on . . . medical gaslighting. September 14, 2022 Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care. August 24, 2022 Skin cancer is a risk no matter the skin tone. But it may be overlooked in people with dark skin. August 17, 2022 Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities. August 10, 2022 Nonopioid directives: unintended consequences in the operating room. June 29, 2022 Implicit racial bias in pediatric orthopaedic surgery. June 15, 2022 The effect of clinician feedback interventions on opioid prescribing. April 27, 2022 Coping and recovery in surgical residents after adverse events: the second victim phenomenon. April 20, 2022 HEAR Her Concerns. April 6, 2022 Preventing home medication administration errors. March 14, 2022 Association of adverse events in opioid addiction treatment with quality measure for continuity of pharmacotherapy. February 16, 2022 Guideline for Prevention of Unintentionally Retained Surgical Items. January 19, 2022 Malpractice cases in breast surgery: an assessment of litigation involving surgeons. December 1, 2021 View More See More About The Topic Operating Room Ambulatory Clinic or Office Health Care Providers Public Health Plastic Surgery View More
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022
Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting. June 24, 2015
Family safety reporting in medically complex children: parent, staff, and leader perspectives. July 6, 2022
Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020
Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems. June 18, 2008
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017
Low rate of completion of recommended tests and referrals in an academic primary care practice with resident trainees. January 31, 2024
Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review. January 12, 2022
Development of a multicomponent intervention to decrease racial bias among healthcare staff. July 27, 2022
Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. July 17, 2013
Association of postoperative readmissions with surgical quality using a Delphi consensus process to identify relevant diagnosis codes. May 16, 2018
Role of pharmacist counseling in preventing adverse drug events after hospitalization. March 22, 2006
Americans' growing exposure to clinician quality information: insights and implications. March 20, 2019
What words convey: the potential for patient narratives to inform quality improvement. April 24, 2019
Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial October 16, 2019
Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes. April 5, 2017
Design and evaluation of simulation scenarios for a program introducing patient safety, teamwork, safety leadership, and simulation to healthcare leaders and managers. August 31, 2011
Improving patient care through leadership engagement with frontline staff: a Department of Veterans Affairs case study. July 31, 2013
Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019. January 4, 2021
Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study. June 7, 2023
Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. November 21, 2007
Health outcomes associated with potentially inappropriate medication use in older adults. April 2, 2008
Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. July 18, 2012
From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. February 26, 2014
The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. February 10, 2021
Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems. March 8, 2006
Development of trigger tools for surveillance of adverse events in ambulatory surgery. November 10, 2010
Validity of selected AHRQ Patient Safety Indicators based on VA National Surgical Quality Improvement program data. October 15, 2008
Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units. November 6, 2013
Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations. March 15, 2017
Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study. January 17, 2024
The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience. May 6, 2009
Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration. March 25, 2009
Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey. September 26, 2007
National hospital ratings systems share few common scores and may generate confusion instead of clarity. March 11, 2015
Safety in numbers: the development of Leapfrog's composite patient safety score for US hospitals. October 16, 2013
Integrating computerized clinical decision support systems into clinical work: a meta-synthesis of qualitative research. November 4, 2015
Journal Article Study Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers. March 29, 2023
Identifying trigger concepts to screen emergency department visits for diagnostic errors. December 16, 2020
Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? August 25, 2021
Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. September 13, 2017
The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program. June 14, 2017
Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. April 22, 2009
The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. February 28, 2007
The evolving literature on safety WalkRounds: emerging themes and practical messages. October 1, 2014
Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers. May 9, 2018
Use of board certification and recertification of pediatricians in health plan credentialing policies. March 8, 2006
Portable advanced medical simulation for new emergency department testing and orientation. May 10, 2006
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018
Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center. August 12, 2020
The I-READI quality and safety framework: a health system’s response to airway complications in mechanically ventilated patients with Covid-19. February 17, 2021
Pediatric musculoskeletal radiographs: anatomy and fractures prone to diagnostic error among emergency physicians. August 3, 2022
A multi-method exploratory evaluation of a service designed to improve medication safety for patients with monitored dosage systems following hospital discharge. October 25, 2023
Interventions for improving teamwork in intrapartem care: a systematic review of randomised controlled trials. October 30, 2019
Preventing harm in the ICU—building a culture of safety and engaging patients and families. July 12, 2017
Differences in the reporting of care-related patient injuries to existing reporting systems. March 6, 2005
Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. May 13, 2009
Real-time automated paging and decision support for critical laboratory abnormalities. August 17, 2011
The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals. February 13, 2013
Improving care transitions: current practice and future opportunities for pharmacists. December 5, 2012
It’s time to consider national culture when designing team training initiatives in healthcare. January 27, 2021
Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis. October 14, 2020
Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: a systematic review and meta-analysis. August 4, 2021
Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review. February 14, 2024
Systems approach to suicide prevention: strengthening culture, practice, and education. June 28, 2023
Stigmatizing language expressed towards individuals with current or previous OUD who have pain and cancer: a qualitative study. June 14, 2023
Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update. May 17, 2023
How should clinicians minimize bias when responding to suspicions about child abuse? February 22, 2023
Advancing diagnostic equity through clinician engagement, community partnerships, and connected care. February 22, 2023
Intended and unintended consequences: changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - controlled and single-series interrupted time series analyses. February 15, 2023
The incidence of opioid misuse among the surgical patients with persistent opioid use. February 8, 2023
How to Stay Safe When Entering the Healthcare System: A Physician Walks across the Country to Raise Awareness of the Need to Improve Healthcare Safety. November 30, 2022
CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. November 16, 2022
Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. October 26, 2022
Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care. August 24, 2022
Skin cancer is a risk no matter the skin tone. But it may be overlooked in people with dark skin. August 17, 2022
Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities. August 10, 2022
Coping and recovery in surgical residents after adverse events: the second victim phenomenon. April 20, 2022
Association of adverse events in opioid addiction treatment with quality measure for continuity of pharmacotherapy. February 16, 2022
Malpractice cases in breast surgery: an assessment of litigation involving surgeons. December 1, 2021