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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-tables-11-12.pdf
March 09, 2018 - Electronic health record has
immunization and medication … Caregiver has access to
electronic health record
Electronic health record has
immunization and medication
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/CombatCare.pdf
March 18, 2014 - Instructor Comments
The pharmacist’s use of a check-back before administering the medication and … resident’s situation awareness and cross-monitoring break an error chain that could have
resulted in a medication … Specialties
Setting: Hospital
It is 0600, and it is time to fill the daily requests of patient medication … LT Downs has an
extensive list to fill before medication is dispensed at 0700. … It is now 0710, and Downs has not filled all of the daily requests of
patient medication.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/ed.pdf
March 19, 2014 - Instructor Comments
The pharmacist’s use of a check-back before administering the medication, and … resident’s situation awareness and cross-monitoring break an error chain that could have
resulted in a medication … Specialties
Setting: Hospital, Pharmacy
It is 0600, and it is time to fill the daily requests of medication … together and discusses the importance of doing check-backs before giving a nebulizer treatment
with a medication … question, she appropriately raises the question
again, which results in the correction of a potential medication
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool11_comm_resource.docx
September 12, 2016 - adult day health; housing authority or housing with service providers; food banks; pharmacies offering medication … starts within 2-3 days of discharge]
[Adult Day provider 2]
[Point person]
[XXX]
[Daily activity, medication … Contact Name, Number:
Service:
Eligibility:
Pharmacy [Name]
Contact Name, Number:
Service: [e.g., medication … Provides supervised medication-assisted treatment with the use of methadone. … Medication assistance available.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/briefing_debriefing.docx
December 01, 2017 - Equipment availability, malfunctions, or concerns
· Critical issues
· Deep vein thrombosis prophylaxis
· Medication … blood glucose less than ________ mg/dL [plan])
· Pain management
· Deep vein thrombosis prophylaxis
· Medication
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-section-2-tech-specs.pdf
November 01, 2014 - Event/
diagnosis
At least two antipsychotic medication dispensing events (Table 1), regardless if … Event/diagnosis At least two antipsychotic medication dispensing events (Table XXX-A), regardless if
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_cord-prolapse.docx
May 01, 2017 - However, pelvic models and props may be needed to substitute for actual medication, blood products, or … Patient moans with every contraction, requests pain medication. … Partner asks nurse for pain medication for his wife.
Partner asks when the baby will be delivered. … Patient moans with every contraction, requests pain medication. … Partner asks nurse for pain medication for his wife.
Partner asks when the baby will be delivered.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/primary-prevention-cvd-with-statins.pdf
May 10, 2018 - concerned about heart disease and stroke and wants
to know whether he should take a cholesterol lowering medication … concerned about heart disease and stroke and wants to know whether he should take a
cholesterol lowering medication … that 33-50% of statin prescriptions
are not filled, and that many patients stop taking their statin medication … Prescribing low-dose generics can help reduce medication cost-related nonadherence. … Patients who develop advanced
dementia can have their statin medication withdrawn, especially if pill
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kleinpeter.pdf
January 01, 2004 - Medication safety
4. Eliminate wrong-site, wrong-patient, wrong-
procedure surgery
4. … Infusion medication safety
6. Improve effectiveness of clinical alarm systems 6. … All medications are obtained from the hospital pharmacy through an
automated medication distribution … system or secured medication rooms in the
clinics. … Nurses verify written medication orders, administer medications, and
monitor the patient for adverse
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Ramanujam.pdf
January 01, 2003 - guiding coalition in the supporting
structures set up to implement change; more frequent review of medication … To encourage health care workers to report medication errors, hospitals
implement a few narrowly focused … likely cause, and “human performance
deficit” remains among the most commonly identified causes of medication … Take, for example, the previously described
situation where nurses stopped reporting when the medication … ); they now call the pharmacy to obtain missing medication, rather than
report these incidents as errors
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfepc-fullguide-final508.pdf
April 01, 2018 - � Medication Errors, including failures in communicating, prescribing, filling, and
dispensing, as … Safety of medication use in primary care. … Frequency of medication errors in primary care
patients with polypharmacy. … Frequency of medication errors in primary
care patients with polypharmacy. … Safety of medication use in primary care.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell_94.pdf
March 30, 2008 - demonstrated a decrease in reported events with major outcomes and an
increase in reported near-miss medication … Implementing clinical best practices or improved technologies—such as
barcoding for medication administration … From 2004 to 2006,
the data reflect increased
reporting of medication near
misses (Table 2, Figure … The proportion of reported
medication near misses to
total reported events also
increased. … Improved near miss reporting
Year
Total reported
events
(N)
Medication
near missesa
(N)
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-5a-evidence-table.pdf
January 01, 2014 - Adverse Drug Event
Detection in Pediatric
Oncology and
Hematology Patients:
Using Medication … An average of 2.68 ADEs
per 1000 doses of medication was
identified. … In a subset of 1,704 charts, the
trigger with the highest percentage yield
was “abrupt medication … Adverse drug
event trigger tool: a
practical methodology for
measuring medication
related harm … Medication
safety program reduces
adverse drug events in a
community hospital.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.docx
April 01, 2011 - Use a reconciled medication list to discuss the purpose of each medicine, how much to take, how to take … Review a reconciled medication list with the patient and family
Hospital identifies one person: Nurse … The toolkit provides clear instructions on creating flowcharts to avoid gaps in reconciling medication … administered throughout the hospital stay, and reconcile medication lists at discharge. … Patients may not be properly informed about food choices, medication side effects, danger signs, and
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/webinars/sdmwebinar1209-slides.pdf
December 09, 2015 - 33% Were unable to read basic health care materials
42% Could not comprehend directions for taking medication … of clinicians, patients, and
caregivers is the impetus
of development
65
Example:
Depression medication … a preference for treatment 69% 92%
Clinician voiced a preference for
treatment 92% 95%
Diabetes medication … usP djO A
al
otT
ea
n
M
LeBlanc et al. in preparation
Rheumatoid arthritis choice
Low literacy medication … of decision making
Shared decision making
Slide Number 64
Slide Number 65
Example: �Depression medication
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/ancillary.pdf
March 19, 2014 - Instructor Comments
The pharmacist’s use of a check-back before administering the medication, and … resident’s situation awareness and cross-monitoring break an error chain that could have
resulted in a medication … together and discusses the
importance of doing check-backs before giving a nebulizer treatment with a medication … Specialties
Setting: Hospital, Pharmacy
The day shift in the Pharmacy receives a new shipment of medication … shifts, the night crew is informed of the new drug derivative so that there is no confusion if the
medication
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
April 01, 2018 - visits
1 in 9
ED admissions
are related to an
adverse drug event
An estimated
160
million
medication
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/dental.pdf
March 19, 2014 - If
given to a pregnant woman, this medication can have adverse effects on the fetus. … The
pharmacist notifies the clinician who chooses and prescribes a different medication. … The
substitute medication is dispensed to the patient.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/smoking-cessation-pcor.pdf
November 01, 2016 - PCOR
research can focus on specific
clinical interventions (such as a
medication or surgical procedure … )
or on ways of delivering care (such
as the use of text messages to
remind people to take a medication
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/aspirin-use-pcor.pdf
November 01, 2016 - PCOR
research can focus on specific
clinical interventions (such as a
medication or surgical procedure … )
or on ways of delivering care (such
as the use of text messages to
remind people to take a medication