Frankel A, Pratt-Grillo S, Graydon-Baker E et al. Patient Safety Leadership WalkRounds™ at Partners HealthCare: Learning from implementation. Joint Commission Journal on Quality and Patient Safety. Aug 2005;31(8):423-437.

In the Patient Safety Leadership WalkRounds™ concept, a core group, which includes the senior executives and/or vice presidents, conducts weekly visits to different areas of the hospital. The group, joined by one or two nurses in the area and other available staff, asks specific questions about adverse events or near misses and about the factors or systems issues that led to these events.  This article describes the lessons learned by Partners HealthCare after implementation of WalkRounds.

Mayo AM, Duncan D. Nurse perceptions of medication errors: What we need to know for patient safety. Journal of Nursing Care Quality. 2004;19(3):209-217.

Descriptive research study of practicing hospital based RNs' perceptions of medication errors (what constitutes a medication error, when to report, frequency of reporting, etc). Provides practical suggestions on how to begin working with hospital RNs to increase reporting of medication errors.

Whittington J, Cohen H. OSF Healthcare’s journey in patient safety. Quality Management in Health Care. 2004;13(1):53-59.

One hospital’s journey toward patient safety — a cultural evolution focused on a strategy for decreasing adverse drug events (ADEs).

Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Standardization as a mechanism to improve safety in health care. Joint Commission Journal on Quality and Safety. 2004;30(1):5-14.

This paper describes two interventions: first, standardization of insulin administration, with the outcome of significantly reducing hypoglycemic events; second, the introduction of medicine reconciliation (“clarifying, correcting and specifying medications”) with a subsequent seven-month chart audit, showing errors falling from 213 per 100 admissions to less than 50.

Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. American Journal of Health-System Pharmacy. 2002;59(22):2221-2225.

This study compared the effectiveness of pharmacist-obtained medication histories with nurse-obtained medication histories. Patients were assigned to either the study or the control group. Pharmacists identified more discrepancies between the patient’s reported home medications and the initial hospital medication orders. Authors conclude that pharmacists are especially suited to conducting medication histories.

Michels RD, Meisel S. Program using pharmacy technicians to obtain medication histories. American Journal of Health-System Pharmacy. 2003;60(19):1982-1986.

Authors describe a pilot program utilizing pharmacy technicians for transitioning outpatient medications to active inpatient orders. This model resulted in a decrease of potential adverse drug events by 80 percent and increase in staff satisfaction. 

Institute for Safe Medication Practices. Use your pre-admission process to enhance safety. Institute for Safe Medications Practices Medication Safety Alert! October 30, 2002:2.

Describes reviewing a patients medication during the pre-admission process for elective admissions as a way to decrease medication errors.

Phillips DP, Christenfeld N, Glynn LM. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998 Feb 28;351(9103):643-644.

This article discusses the increase of deaths in the United States resulting from medication errors.

Draper S, Nielsen GA, Noland M. Using "no problem found" in infusion pump programming as a springboard for learning about human factors engineering. Joint Commission Journal of Quality and Safety. 2004;30(9):515-520.

Device design frequently contributes to errors previously blamed on the users, as reflected in this account of how a hospital new to human factors engineering addressed a case in which no malfunction was evident.

This article is one of 11 articles from the Journal's 2004 Human Factors Engineering (HFE) series, edited by John Gosbee, MD. All the articles, along with an HFE overview by Laura Lin Gosbee, MA.Sc., are available in a new publication, Using Human Factors Engineering to Improve Patient Safety.

Full Text Available!  Click View Article below.

Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: Results of a US consensus panel of experts. Archives of Internal Medicine. Dec 2003;163(22):2716-2724.

This article is the foundation for what nursing homes across the United States are using to define inappropriate prescribing. There is an increased risk for medical and safety consequences, most notably falls, in the elderly population as a result of inappropriate prescribing.