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Preventing Medication Errors (2007) / Chapter Skim
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7 Applied Research Agenda for Safe Medication Use
Pages 310-327

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From page 310...
... Recommendation 6: The Agency for Healthcare Research and Quality (AHRQ) should take the lead, working with other govern ment agencies such as the Centers for Medicare and Medicaid Services (CMS)
From page 311...
... DEFINITIONS Researchers use a variety of definitions for medication errors, near misses, and adverse drug events (ADEs)
From page 312...
... Thus the committee recommends pursuit of a research agenda aimed at delineating effective strategies for involving patients and their families in the prevention, early detection, and mitigation of harm due to medication errors (IOM, 2004) , with particular focus on the following topics: · Determining how best to present information to patients to facilitate their understanding of medication use and safety, including the development of a consumer-friendly nomenclature for representing this information.
From page 313...
... and complementary and alternative medications. Hospital Care Medication error rates in hospitals have been relatively well researched.
From page 314...
... Ambulatory Care In the ambulatory setting, the best-understood aspects of medication error rates are prescribing errors in ambulatory primary care clinics and dispensing errors in community pharmacies. There is some understanding of the incidence of ADEs in ambulatory care and self-care errors.
From page 315...
... The committee believes medication errors in inpatient and outpatient psychiatry require more study. Psychiatrist professional organizations have only recently identified medication errors as a patient safety and quality concern.
From page 316...
... , all of the studies related to hospital care. Clearly there are large gaps in our understanding of the costs of 1These networks are defined by the Agency for Healthcare Research and Quality as a group of ambulatory practices devoted principally to the primary care of patients, affiliated with each other (and often with an academic or professional organization)
From page 317...
... Prevention Strategies The committee acknowledges that it is not possible to put forward a fully comprehensive set of corrective medication error strategies. The area best understood is the incidence of medication errors and preventable ADEs in various care settings where significant problems and their causes have been identified.
From page 318...
... is almost universally recommended, as is incorporating clinical pharmacists into the inpatient medical team during daily rounds and creating specialized protocols for high-alert medications. Other strategies for which the evidence is not as strong but that are commonly recommended include standardizing prescription writing, limiting oral orders, improving medication error identification systems, adopting system-based approaches to reducing medication errors, promoting a culture of safety, implementing bar coding, and using unit dosing.
From page 319...
... The impact of staffing levels on medication errors and preventable ADEs in the nursing home setting also has not been adequately studied, nor have deficiencies in communication between nursing home staff and the clinicians accountable for prescribing medications. Ambulatory Care Many approaches to medication safety derive from the inpatient setting, and it is not clear to what extent these approaches are transferable to the ambulatory setting.
From page 320...
... Most of the research to date on pediatric medication errors has been skewed toward prescribing errors. The committee's review of data from error reporting systems revealed that dispensing and administering are as error prone as prescribing.
From page 321...
... · Better patient education in the use of medications. A number of computerized interventions also appear to have the potential to decrease medication error rates in the psychiatric inpatient setting.
From page 322...
... The CCR is a standard specification developed jointly by the American Society for Testing Materials (ASTM) International, the Massachusetts Medical Society, the Health Information Management and Systems Society, the American Academy of Family Physicians, the American Academy of Pediatrics, and others (Tessier, 2005)
From page 323...
... Research is needed on what data sources are necessary for a robust background monitoring system in the ambulatory environment, such as the systems used for inpatients at Brigham and Women's Hospital in Boston, Massachusetts, and LDS Hospital in Salt Lake City, Utah. Development and testing of such systems would be a major step forward in medication safety in the ambulatory setting, particularly if facilitated by the incorporation of electronic health records and electronic prescribing.
From page 324...
... 1997. The costs of adverse drug events in hospitalized patients.
From page 325...
... 1997. Adverse drug events in hospitalized patients.
From page 326...
... 2005. The incidence of adverse drug events in two large academic long-term care facilities.
From page 327...
... 2001. Practical approach to determining costs and frequency of adverse drug events in a health care network.


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