Medication errors

Innovations

Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use 05/17/10

Care staff use software-based protocols to screen older clients' medications and collaborate with pharmacists and physicians to reduce the risk of medication errors and adverse effects, leading to more appropriate medication use and fewer cases of duplicative medications.

VA Patients Use Waiting Room Kiosk to Enter Medication List, Facilitating Reconciliation With Electronic Medical Record and Identifying More Discrepancies 05/06/10

Clinic providers compare patients' self-reported medication lists (generated through an easy-to-use automated system featuring a computer kiosk and simple touchscreen interface) to medications listed in the electronic medical record, allowing them to adhere more closely to established medication reconciliation practices and to identify and address more medication discrepancies, including potentially lethal ones.

Pharmacists Monitor Hypertensive Patients and Make Recommendations to Physicians, Leading to Better Blood Pressure Control and Increased Physician Adherence to Established Guidelines 04/20/10

Clinical pharmacists collaborated with physicians to manage patients with uncontrolled high blood pressure by assessing the causes of poor blood pressure control, developing a guideline-based care plan, monitoring the patient's treatment response, and making recommendations for medication additions and adjustments as needed, leading to better blood pressure control and increased physician adherence to established guidelines.

Sleep Education and Other Support Significantly Reduces Turnover Among First-Year Nurses 03/17/10

A nurse retention program that incorporates sleep education and other support significantly reduced nurse turnover among first-year nurses.

Monthly Multidisciplinary Patient Safety Conferences Improve Hospital Staff Perceptions of Organization's Safety Culture and Increase Reporting of Adverse Events 02/09/10

Monthly patient safety conferences that allow clinicians and all levels of staff to openly discuss adverse events improved staff perceptions of the organization's safety culture and increased the reporting of such events.

Regular Reminders via Text Message Increase Adherence to Medication Regimen, Significantly Reduce Risk of Organ Rejection in Pediatric Liver Transplant Patients 11/20/09

Regular reminders via text message enhance adherence to medication regimens and reduce risk of organ rejection in pediatric liver transplant patients.

Real-Time, Resident-Specific Medication Information and Alerts, Supported by Medication Safety Teams, Enhance Efficiency and Reduce Medication Errors in Nursing Homes 09/30/09

Real-time, resident-specific medication information and alerts, with support from a medication safety team, enhanced the efficiency of medication administration and reduce medication errors.

Use of Photographs as Second Means of Identifying Patients on Psychiatry Units Virtually Eliminates Medication Errors Related to Misidentification 08/04/09

Use of photographs as a second means of identifying patients on adult and adolescent psychiatry units virtually eliminates medication errors due to patient misidentification.

Nurse Practitioner–Led Transitional Care Program Does Not Reduce Readmissions During Period Between Discharge and Followup Appointment 01/16/09

A nurse practitioner–led service to bridge the gap in care for recently discharged patients awaiting a followup appointment did not reduce the rate of unplanned readmissions.

Intravenous Infusion Safety Initiative Prevents Medication Errors, Leading to Cost Savings and High Nurse Satisfaction 11/06/08

A two-hospital system implemented an intravenous infusion safety initiative that has helped avoid many infusion-related errors, leading to significant cost savings and high levels of nurse satisfaction.

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