Findings from the ISMP Medication Safety Self-Assessment® for Hospitals
The Joint Commission Journal on Quality and SafetyPublished 1 November 2003
Judy L. Smetzer, Allen J. Vaida, Michael R. Cohen, Diane Tranum, Mary Pittman, Carl W. Armstrong
Citations60
Generate an AI Snapshot to get a quick, structured summary of this paper.
Study Snapshot
ObjectiveStudy objective
MethodsResearch methodology
PopulationPopulation studied
Sample sizeSample sizes
OutcomesStudy outcomes here
ResultsStudy results comes here
LimitationsResearch study limitations comes here
A concise AI-generated summary of the paper will appear here once you click Generate AI Snapshot.
TL;DR
Enormous opportunities exist to improve medication safety, especially in domains related to culture, information management, and communication.
Abstract
Enormous opportunities exist to improve medication safety, especially in domains related to culture, information management, and communication.
Keywords
MedicineHealth Professions
National Academies Press eBooksTo Err Is Human
14,096 Citations2000Institute of Medicine
A process for the preparation of prostaglandins which are known pharmaceutically active compounds and then R alpha , R omega -cyclopentenoids is described.
BMJCrossing the Quality Chasm: A New Health System for the 21st Century
10,744 Citations2001Alexi Baker
Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.
Medical Entomology and ZoologyMultiple regression in behavioral research
4,886 Citations1973Fred N. Kerlinger, Elazar J. Pedhazur
New England Journal of MedicineIncidence of Adverse Events and Negligence in Hospitalized Patients
4,666 Citations1991Troyen A. Brennan, Lucian L. Leape +7 more
The incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care, in New York State in 1984 were estimated.
New England Journal of MedicineThe Nature of Adverse Events in Hospitalized Patients
3,750 Citations1991Lucian L. Leape, Troyen A. Brennan +8 more
The high proportion that are due to management errors suggests that many others are potentially preventable now, and reducing the incidence of these events will require identifying their causes and developing methods to prevent error or reduce its effects.
JAMAIncidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group
2,509 Citations1995David W. Bates
Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable and prevention strategies should target both stages of the drug delivery process.
JAMAIncidence of Adverse Drug Events and Potential Adverse Drug Events
2,118 Citations1995David W. Bates
Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable and prevention strategies should target both stages of the drug delivery process.
JAMAEffect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors
2,091 Citations1998David W. Bates
Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.
JAMAMedication Errors and Adverse Drug Events in Pediatric Inpatients
1,932 Citations2001Rainu Kaushal
Medication errors are common in pediatric inpatient settings, and further efforts are needed to reduce them.
JAMAAdverse Drug Events in Hospitalized Patients<subtitle>Excess Length of Stay, Extra Costs, and Attributable Mortality</subtitle>
1,108 Citations1997David C. Classen
The attributable lengths of stay and costs of hospitalization for ADEs are substantial and an ADE is associated with a significantly prolonged length of stay, increased economic burden, and an almost 2-fold increased risk of death.
JAMAFactors Related to Errors in Medication Prescribing
712 Citations1997Timothy S. Lesar
By improving the focus of organizational, technological, and risk management educational and training efforts using the factors commonly associated with prescribing errors, risk to patients from adverse drug events should be reduced.
JAMAComputerized Surveillance of Adverse Drug Events in Hospital Patients
640 Citations1991David C. Classen
Annals of Emergency MedicineThe Potential for Improved Teamwork to Reduce Medical Errors in the Emergency Department
582 Citations1999Daniel T. Risser, Matthew Rice +4 more
This article describes emergency department care work teams designed to improve team communication and coordination and reduce error, which are key teamwork concepts largely drawn from successful aviation programs.
American Journal of Health-System PharmacyPractical approach to determining costs and frequency of adverse drug events in a health care network
305 Citations2001Bonnie L. Senst, Louis E. Achusim +6 more
ADEs were frequent, costly, and often preventable and resulted in many admissions to a mental health center and resulted at the prescribing stage of the medication-use process.
Journal of Clinical NursingFactors contributing to medication errors: a literature review
271 Citations1999Ellen O’Shea
What constitutes a medication error and contributory factors in medication errors are examined and a multidisciplinary approach is required in order to reduce the incidence of errors.
Archives of Pediatrics and Adolescent MedicineHow Can Information Technology Improve Patient Safety and Reduce Medication Errors in Children's Health Care?
204 Citations2001Rainu Kaushal, Kenneth N. Barker +1 more
The role of information technology in decreasing pediatric medication errors in both inpatient and outpatient settings is reviewed and personalized Web pages and World Wide Web-based information have substantial potential.
The Joint Commission Journal on Quality ImprovementReducing Adverse Drug Events: Lessons from a Breakthrough Series Collaborative
197 Citations2000Lucian L. Leape, Andrea Kabcenell +4 more
Success in making significant changes was associated with strong leadership, effective processes, and appropriate choice of intervention and teams were able to define, clearly state, and relentlessly pursue their aims.
Annals of Emergency MedicineAdverse drug events in emergency department patients
177 Citations2002John W. Hafner, Steven M. Belknap +2 more
ED screening may provide useful information about the epidemiology of outpatient ADEs, and encompassed an important segment of ED encounters and annual health care costs.
The Joint Commission Journal on Quality ImprovementPatient Safety and Computerized Medication Ordering at Brigham and Women’s Hospital
155 Citations2001Gilad J. Kuperman, Jonathan M. Teich +2 more
CPOE and several forms of clinical decision support targeted at increasing patient safety have substantially decreased the frequency of serious medication errors and have had an even bigger impact on the overall medication error rate.
International Journal for Quality in Health CareMethodology matters. Identifying drug safety issues: from research to practice
130 Citations2000Tapan Kumar Gandhi, David B. Seder +1 more
Health care organizations have the technology to significantly improve their detection of ADEs, medication errors, and potential ADEs and should be adopted by organizations.
American Journal of Health-System PharmacyNaming, labeling, and packaging of pharmaceuticals
102 Citations2001John W. Kenagy, Gary C. Stein
Drug names, labels, and packages are not selected and designed in accordance with human factors principles, the drug industry has struggled with change, and private-sector initiatives have had only limited success.
BMJEnhancing public safety in primary care
100 Citations2002Timothy D. Wilson
This paper considers public safety in primary care and proposes a strategic response to the pressing challenge of improving the safety record of primary care.
Journal of General Internal MedicinePrescribing errors involving medication dosage forms
96 Citations2002Timothy S. Lesar
Hospitalized patients are at risk for adverse outcomes due to prescribing errors related to inappropriate use of medication dosage forms, and this information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors.
British Journal of HaematologyMEDICATION ERRORS: CAUSES, PREVENTION AND REDUCTION
91 Citations2002Jonathan M. Allard, Jane Carthey +3 more
Research on medication errors during drug delivery and transfusion medicine is reviewed with a view to understanding the underlying latent conditions (i.e. systems problems) that contribute to them.
Annals of Emergency MedicineHuman Error in Emergency Medicine
83 Citations1999Robert L. Wears, Lucian L. Leape
Abstract [Wears RL, Leape LL: Human error in emergency medicine]; Ann Emerg Med September 1999;34:370-372.
Journal of Clinical AnesthesiaPrevention of adverse drug events: a decade of progress in patient safety
81 Citations2000David J. Cullen, David W. Bates +1 more
Until the initial Harvard Medical Practice Study provided data that indicated a serious problem existed in other areas of medicine and surgery across a broad spectrum of hospitals and patient care settings, little was being done to address the more generalized problems of human error in medicine.
American Journal of Health-System PharmacyResearch on drug-use-system errors
68 Citations1995Kenneth N. Barker, Elizabeth Louise Allan
American Journal of Health-System PharmacyPotential risks and prevention, part 1: Fatal adverse drug events
68 Citations2001William N. Kelly
Sixty-eight percent of the fatal ADEs were judged to have been preventable; of these, a pharmacist could have prevented 57%.
Pediatric DrugsCommon Errors of Drug Administration in Infants
56 Citations1999Brian J. Anderson, John F. Ellis
The goal of a zero drug error rate should be aggressively sought, with systems in place that aim to eliminate the effects of inevitable human error, and policies using interventions both specific and general to reduce the number of errors made in giving medication to infants.
The Journal of Continuing Education in NursingSearching for the Final Answer: Factors Contributing to Medication Administration Errors
42 Citations2001Tess M. Pape
Patients have enough fears when entering health care institutions; medication errors should not be one of them unless health care providers are willing and able to focus attention where it is needed-on systems rather than individuals.
The Joint Commission Journal on Quality ImprovementReducing Medication Errors in Hospitals: A Peer Review Organization Collaboration
38 Citations2000Michael Silver, Juli A. Antonow
American Journal of Health-System PharmacyNew perspectives on preventing medication errors and adverse drug events
38 Citations2000Vicki S. Crane
American Journal of Health-System PharmacyInto the abyss: Seven principles for identifying the causes of and preventing human error in complex systems
37 Citations2000Anthony F. Grasha
The Joint Commission Journal on Quality and SafetyUsing the ISMP Medication Safety Self-Assessment™ to Improve Medication Use Processes
22 Citations2003Timothy S. Lesar, Arnold Mattis +5 more
Participant progress in improving medication safety practices is supportive of collaborative methods and the value of completing the ISMP self-assessment, expanding on the knowledge gained, developing effective implementation tools, and systematically applying lessons learned.
British Journal of HaematologyCAN WE PREVENT CYTOTOXIC DISASTERS?
9 Citations2000Conrad V. Fernandez
The purpose of this review is to explore the realm of cytotoxic disaster, which results in the accidental injury or death of a patient through an error or series of errors of chemotherapy administration, and to examine how a better understanding of the processes that lead to these errors may help to reduce future catastrophic accidental events.