Clinical pharmacists working in 13 community health centers provide medication reconciliation, monitoring, dosage adjustments, and education to high-risk patients, including those with severe diabetes and those on anticoagulants.
The West Los Angeles Healthcare Center implemented a program to improve nurses' and patients' awareness and reporting of medication allergies and adverse drug reactions. Key program elements include a training module for nurses, educational brochures for patients, and distribution of an allergy/adverse drug reaction questionnaire to patients.
Safety mentors at Christiana Care Health System help staff implement best-practice safety behaviors and reporting of errors and near misses, leading to a reduction in serious adverse events and increased identification and/or reporting of near misses.
The Healthcare Alliance Safety Partnership was a 3-year pilot project involving a board of nursing and three hospital systems in developing a voluntary, nonpunitive system for reporting, investigating, and analyzing nursing errors.
The Mayo Clinic Department of Medicine developed a computer-generated, customized medication education and reminder card for patients discharged on multiple medications; the card was tested as an alternative to the medication discharge worksheet commonly used by nurses at Mayo.
Contra Costa Health Services launched a medication reconciliation process at its county-owned hospital based on Institute for Healthcare Improvement concepts for redesigning work to achieve a high degree of reliability. The institution uses a process in which providers, pharmacy, and nursing staff have standardized, easy-to-understand, and easy-to-execute roles related to medication reconciliation.
Reconciling patient and provider medication lists reduces discrepancies, leading to enhanced medication safety and high levels of patient and provider satisfaction in the outpatient setting.
A hospital's ambulatory pediatrics department developed a voluntary, anonymous, and nonpunitive medical error reporting system that includes a quick response team to review reports and enact interventions to prevent recurrences, leading to a significant increase in error reporting.
A randomized clinical trial at San Francisco General Hospital used visual medication schedules and brief teach-back protocols in English, Spanish, and Cantonese to improve anticoagulant control among low-literacy patients in the public hospital's anticoagulation clinic.
The Dana-Farber Cancer Institute uses safety rounds with staff and patients, supported by a toolkit, to promote a culture of safety and reduce medical errors by proactively identifying and addressing potential safety problems.