A new leadership role for pharmacists: a prescription for change.

Abstract:

OBJECTIVE:Pharmacists can play an important role as leaders to reduce patient safety risks, optimize the safe function of medication management systems, and align pharmacy services with national initiatives that measure and reward quality performance. The objective of this article is to determine the actions that pharmacists can take to create a visible and sustainable safe medication management structure and system in the health care environment. METHODS:An evidence-based literature search was performed to determine what actions successful pharmacist leaders have taken to improve patient safety. RESULTS:There is a growing number of quality and patient safety standards, as well as measures that focus specifically on medication use and education. Health care organizations must be made aware of the valuable resources that pharmacists provide and of the complexity of medication management. There are steps that pharmacist leaders can take to achieve these goals. CONCLUSIONS:The 10 steps that pharmacist leaders can take to create a visible and sustainable safe medication management structure and system are the following: 1. Identify and mitigate medication management risks and hazards to reduce preventable patient harm. 2. Establish pharmacy leadership structures and systems to ensure organizational awareness of medication safety gaps. 3. Support an organizational culture of safe medication use. 4. Ensure evidence-based medication regimens for all patients. 5. Have daily check-in calls/meetings, with the primary focus on significant safety or quality issues. 6. Establish a medication safety committee. 7. Perform medication safety walk-rounds to evaluate medication processes, and request front-line staff ’s input about medication safe practices. 8. Ensure that pharmacy staff engage in teamwork, skill building, and communication training. 9. Engage in readiness planning for implementation of health information technology (HIT). 10. Include medication history-taking and reviews upon entry into the organization; medication counseling and training during the discharge process; and follow-up after the transition to home.

journal_name

J Patient Saf

authors

Burgess LH,Cohen MR,Denham CR

doi

10.1097/PTS.0b013e3181d108cb

subject

Has Abstract

pub_date

2010-03-01 00:00:00

pages

31-7

issue

1

eissn

1549-8417

issn

1549-8425

pii

01209203-201003000-00005

journal_volume

6

pub_type

杂志文章
  • Physical Design Factors Contributing to Patient Falls.

    abstract:OBJECTIVES:The aim of this study was to identify physical design elements that contribute to potential falls in patient rooms. METHODS:An exploratory, physical simulation-based approach was adopted for the study. Twenty-seven subjects, older than 70 years (11 male and 16 female subjects), conducted scripted tasks in a...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000339

    authors: Pati D,Valipoor S,Cloutier A,Yang J,Freier P,Harvey TE,Lee J

    更新日期:2017-02-03 00:00:00

  • Evaluation of Learning Teams Versus Root Cause Analysis for Incident Investigation in a Large United Kingdom National Health Service Hospital.

    abstract:INTRODUCTION:Significant resource is invested into investigation of adverse healthcare events. Outcomes of such investigations have varying degrees of effectiveness. The "hierarchy of effectiveness" model proposes system-focused changes have greater impact than person-focused actions. The traditional approach to invest...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000641

    authors: Robbins T,Tipper S,King J,Ramachandran SK,Pandit JJ,Pandit M

    更新日期:2020-03-24 00:00:00

  • In-Hospital Fall and Fracture Risk With Conditions in the Elixhauser Comorbidity Index: An Analysis of State Inpatient Data.

    abstract:OBJECTIVE:In-hospital falls (IHFs) are a significant burden to the healthcare industry and patients seeking inpatient care. Many falls lead to injuries that could be considered a hospital-acquired condition (HAC). We demonstrated how administrative data can be used to quantify how many IHFs occur and identify what cond...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000637

    authors: Davis J,Casteel C,Peek-Asa C

    更新日期:2020-03-11 00:00:00

  • Predictors of Patients' Intentions to Participate in Incident Reporting and Medication Safety.

    abstract:BACKGROUND:To date, there is a paucity of theory-driven research on the likely determinants of patient involvement in safety-relevant behaviors. In particular, very little work has focused on predictors of patient behaviors that do not involve direct interactions with health-care staff. OBJECTIVE:To examine predictors...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000068

    authors: Davis RE,Vincent C,Sevdalis N

    更新日期:2015-12-01 00:00:00

  • An NTSB for health care: learning from innovation: debate and innovate or capitulate.

    abstract:INTRODUCTION:Economic and medical risks threaten the national security of America. The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable s...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3182446c51

    authors: Denham CR,Sullenberger CB 3rd,Quaid DW,Nance JJ

    更新日期:2012-03-01 00:00:00

  • Use of Designated Nurse PICC Teams and CLABSI Prevention Practices Among U.S. Hospitals: A Survey-Based Study.

    abstract:OBJECTIVES:The use of peripherally inserted central catheters (PICCs) has increased substantially within hospitals during the past several years. Yet, the prevalence and practices of designated nurse PICC teams (i.e., specially trained nurses who are responsible for PICC insertions at a hospital) are unknown. We, there...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000246

    authors: Krein SL,Kuhn L,Ratz D,Chopra V

    更新日期:2019-12-01 00:00:00

  • Involvement in Root Cause Analysis and Patient Safety Culture Among Hospital Care Providers.

    abstract:BACKGROUND:The experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team. OBJECTIVE:The aim of the study was to determine whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS),...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000456

    authors: Boussat B,Seigneurin A,Giai J,Kamalanavin K,Labarère J,François P

    更新日期:2017-12-27 00:00:00

  • Frequency of Passive EHR Alerts in the ICU: Another Form of Alert Fatigue?

    abstract:OBJECTIVES:The intensive care unit (ICU) is a complex environment in terms of data density and alerts, with alert fatigue, a recognized barrier to patient safety. The Electronic Health Record (EHR) is a major source of these alerts. Although studies have looked at the incidence and impact of active EHR alerts, little r...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000270

    authors: Kizzier-Carnahan V,Artis KA,Mohan V,Gold JA

    更新日期:2019-09-01 00:00:00

  • Cross-Cultural Adaptation and Psychometric Evaluation of a Second Victim Experience and Support Tool (SVEST).

    abstract:INTRODUCTION:The second victim is defined as the health professionals who commit an error and are traumatized by the event manifesting psychological, cognitive, and/or physical reactions that have a personal negative impact.The SVEST (Second Victim Experience and Support Tool) is a survey developed and validated in the...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000497

    authors: Brunelli MV,Estrada S,Celano C

    更新日期:2018-05-03 00:00:00

  • Between choice and chance: the role of human factors in acute care equipment decisions.

    abstract:OBJECTIVES:We report on a human factors evaluation project at a major urban teaching hospital that was intended to use human factors methods to assist the selection of a new infusion device among 4 commercially available models. METHODS:The project provided an expert evaluation of the pumps, collected data on programm...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3181a974d9

    authors: Nemeth C,Nunnally M,Bitan Y,Nunnally S,Cook RI

    更新日期:2009-06-01 00:00:00

  • Triggers Contributing to Health Care Clinicians' Disruptive Behaviors.

    abstract:OBJECTIVES:This study's objective was to explore the possible triggers of clinicians' disruptive behavior and to consider whether the type of trigger resulting in disruptive behavior differed by type of clinician, clinician characteristics, professional role, and ethnic background. METHODS:Using data collected from 15...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000288

    authors: Bae SH,Dang D,Karlowicz KA,Kim MT

    更新日期:2020-09-01 00:00:00

  • Changes to Hospital Inpatient Volume After Newspaper Reporting of Medical Errors.

    abstract:OBJECTIVE:The aim of this study was to investigate the influence of medical error case reporting by national newspapers on inpatient volume at acute care hospitals. DESIGN:A case-control study was conducted using the article databases of 3 major Japanese newspapers with nationwide circulation between fiscal years 2012...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000349

    authors: Fukuda H

    更新日期:2017-06-30 00:00:00

  • The effect of hospital organizational characteristics on postoperative complications.

    abstract:OBJECTIVES:To determine if there is a relationship between the risk of postoperative complications and the nonclinical hospital characteristics of bed size, ownership structure, relative urbanicity, regional location, teaching status, and area income status. METHODS:This study involved a secondary analysis of 2006 adm...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3182995e5b

    authors: Knight M

    更新日期:2013-12-01 00:00:00

  • Impact of an Obstetrical Hospitalist Program on the Safety Events in a Mid-Sized Obstetrical Unit.

    abstract:OBJECTIVE:Because internal medicine hospitalist programs were developed to address issues in medicine such as a need to improve quality, improve efficiency, and decrease healthcare cost, obstetrical (OB) hospitalist models were developed to address needs specific to the obstetrics and gynecology field. Our objective wa...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000397

    authors: Decesare JZ,Bush SY,Morton AN

    更新日期:2020-09-01 00:00:00

  • Identification and description of randomized controlled trials and systematic reviews on patient safety published in medical journals.

    abstract:OBJECTIVE:To identify and describe randomized controlled trials (RCTs) and systematic reviews (SRs) on patient safety published from 1973 onward. MATERIALS AND METHODS:We handsearched a total of 12 medical journals published in English with contents related to patient safety to identify RCTs and SRs published between ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e31827cda38

    authors: Barajas-Nava LA,Calvache JA,López-Alcalde J,Solà I,Cosp XB

    更新日期:2013-06-01 00:00:00

  • Prescriber Compliance With Liver Monitoring Guidelines for Pazopanib in the Postapproval Setting: Results From a Distributed Research Network.

    abstract:OBJECTIVES:Pazopanib received US Food and Drug Administration approval in 2009 for advanced renal cell carcinoma. During clinical development, liver chemistry abnormalities and adverse hepatic events were observed, leading to a boxed warning for hepatotoxicity and detailed label prescriber guidelines for liver monitori...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000332

    authors: Shantakumar S,Nordstrom BL,Hall SA,Djousse L,van Herk-Sukel MPP,Fraeman KH,Gagnon DR,Chagin K,Nelson JJ

    更新日期:2019-03-01 00:00:00

  • Implementation of a Patient-Provider Agreement to Improve Healthcare Delivery for Patients With Substance Use Disorder in the Inpatient Setting.

    abstract:OBJECTIVES:Inpatient healthcare delivery to people who use drugs is an opportunity to provide acute medical stabilization and offer treatment for underlying substance use disorder (SUD). The process of delivering quality healthcare to people with SUD can present challenges. METHODS:We convened a group of stakeholders ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000721

    authors: Wurcel AG,Yu S,Burke D,Lund A,Schelling K,Weingart SN,Freund KM

    更新日期:2020-05-07 00:00:00

  • A public health approach to patient safety reporting systems is urgently needed.

    abstract::Patient safety reporting systems (PSRSs) currently operate at local, regional, and national levels within health care. This article analyzes 6 different PSRSs using a World Health Organization and public health classification system. Patient safety incidents (PSIs) are reported, analyzed, mitigated, and evaluated in a...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e31821b8a6c

    authors: Noble DJ,Panesar SS,Pronovost PJ

    更新日期:2011-06-01 00:00:00

  • Missed Acute Coronary Syndrome During Telephone Triage at Out-of-Hours Primary Care: Lessons From A Case-Control Study.

    abstract:OBJECTIVES:Serious adverse events at out-of-hours services in primary care (OHS-PC) are rare, and the most often concern is missed acute coronary syndrome (ACS). Previous studies on serious adverse events mainly concern root cause analyses, which highlighted errors in the telephone triage process but are hampered by hi...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000799

    authors: Erkelens DC,Rutten FH,Wouters LT,Kirkels HG,Poldervaart JM,de Groot E,Damoiseaux RA,Hoes AW,Zwart DL

    更新日期:2020-12-14 00:00:00

  • Outpatient adverse drug events identified by screening electronic health records.

    abstract:OBJECTIVES:Relatively little is known about rates of outpatient adverse drug events (ADEs), and most health systems do not routinely identify them. We developed a computerized ADE measurement process and used it to detect ADEs from electronic health records and then categorized them according to type, preventability, a...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3181dcae06

    authors: Gandhi TK,Seger AC,Overhage JM,Murray MD,Hope C,Fiskio J,Teal E,Bates DW

    更新日期:2010-06-01 00:00:00

  • Development of a Trigger Tool to Identify Adverse Drug Events in Elderly Patients With Multimorbidity.

    abstract:PURPOSE:Elderly patients with multimorbidity are especially vulnerable to adverse drug events (ADEs) and had high prevalence rates. Identifying ADEs is essential for enabling timely interventions that can mitigate the adverse events detected and for developing targeted strategies to prevent their occurrence as well as ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000389

    authors: Toscano Guzmán MD,Galván Banqueri M,Otero MJ,Alfaro Lara ER,Casajus Lagranja P,Santos Ramos B

    更新日期:2017-06-14 00:00:00

  • Adherence to the 2010 American College of Cardiology Foundation Appropriate Use Criteria for Cardiac Computed Tomography: Quality Analysis at a Tertiary Referral Center.

    abstract:BACKGROUND:In November 2010, the American College of Cardiology Foundation published revised appropriateness criteria (AC) for cardiac computed tomography (CT). We evaluated adherence to these criteria by providers of different subspecialties at a tertiary referral center. METHODS:Reports of 383 consecutive patients w...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000124

    authors: Sidhu MS,Lumish H,Uthamalingam S,Engel LC,Abbara S,Brady TJ,Hoffmann U,Ghoshhajra BB

    更新日期:2016-03-01 00:00:00

  • UDI2Claims: Planning a Pilot Project to Transmit Identifiers for Implanted Devices to the Insurance Claim.

    abstract:BACKGROUND:In response to problems with the current postmarket surveillance of medical devices, the U.S. Food and Drug Administration mandated device labelers to include a unique device identifier (UDI), composed of a device identifier (DI) and production identifier. Including the DI in insurance claims could be a pote...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000543

    authors: Zerhouni YA,Krupka DC,Graham J,Landman A,Li A,Bhatt DL,Nguyen LL,Capatch K,Concheri K,Reich AJ,Wilson N,Weissman JS

    更新日期:2018-11-21 00:00:00

  • Is Communication Improved With the Implementation of an Obstetrical Version of the World Health Organization Safe Surgery Checklist?

    abstract:OBJECTIVE:Communication failures are consistently seen as a root cause of preventable adverse outcomes in obstetrics. We assessed whether use of an Obstetric Safe Surgery Checklist for cesarean deliveries (CDs), based on the WHO Safe Surgery Checklist, can improve communication; reduce team member confusion about urgen...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000327

    authors: Govindappagari S,Guardado A,Goffman D,Bernstein J,Lee C,Schonfeld S,Angert R,McGowan A,Bernstein PS

    更新日期:2020-12-01 00:00:00

  • Encouraging Patients to Speak up About Problems in Cancer Care.

    abstract:OBJECTIVES:Many patients with cancer believe that something has gone wrong in their care but are reluctant to speak up. This pilot study sought to evaluate the impact of an intervention of active outreach to patients undergoing cancer treatment, wherein patients were encouraged to speak up if they had concerns about th...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000510

    authors: Mazor KM,Kamineni A,Roblin DW,Anau J,Robinson BE,Dunlap B,Firneno C,Gallagher TH

    更新日期:2018-06-27 00:00:00

  • Frequency and Severity of Adverse Drug Events by Medication Classes: The JADE Study.

    abstract:OBJECTIVE:Adverse drug events (ADEs) are a significant concern in daily practice; however, the profile of high-risk drugs remains unclear. Our objective was to categorize high-risk medication classes according to frequency and severity of ADEs. METHODS:The JADE study is a prospective cohort study of 3459 hospitalized ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000235

    authors: Sakuma M,Kanemoto Y,Furuse A,Bates DW,Morimoto T

    更新日期:2020-03-01 00:00:00

  • Patient Safety Activity Under the Social Insurance Medical Fee Schedule in Japan: An Overview of the 2010 Nationwide Survey.

    abstract:OBJECTIVES:Little is known about patient safety performance under the social insurance medical fee schedule in Japan. The Health Ministry in Japan introduced the preferential patient safety countermeasure fee (PPSCF) to promote patient safety in 2006 and revised the PPSCF system in 2010. This study aims to address the ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000432

    authors: Hirose M,Kawamura T,Igawa M,Imanaka Y

    更新日期:2017-11-16 00:00:00

  • An Evaluation of Shared Mental Models and Mutual Trust on General Medical Units: Implications for Collaboration, Teamwork, and Patient Safety.

    abstract:OBJECTIVES:This study examines nurse-physician teamwork and collaboration, a critical component in the delivery of safe patient care, on general medical units. To that end, we assess shared mental models and mutual trust, 2 coordinating mechanisms that help facilitate teamwork, among nurses and physicians working on ge...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000151

    authors: McComb SA,Lemaster M,Henneman EA,Hinchey KT

    更新日期:2017-12-01 00:00:00

  • 2009 Annual National Patient Safety Foundation Congress: conference proceedings.

    abstract::On May 20 to 22, 2009, the National Patient Safety Foundation (NPSF) held its Annual NPSF Patient Safety Congress in National Harbor, Md. Entitled Patient Safety in Challenging Times: Now More Than Ever, A Critical Need, the meeting focused on the need to strengthen efforts to improve patient safety and quality in the...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/pts.0b013e3181b5cb8a

    authors: Bonacum D,Corrigan J,Gelinas L,Pinakiewicz DC,Stepnick L

    更新日期:2009-09-01 00:00:00

  • Does Physician's Training Induce Overconfidence That Hampers Disclosing Errors?

    abstract:PURPOSE:Although transparency is critical for reducing medical errors, physicians feel discomfort with disclosure. We explored whether overconfidence relates to physician's reluctance to admit that an error may have occurred. METHOD:At 3 university medical centers, a survey presented a clinical vignette of a girl with...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000255

    authors: Brezis M,Orkin-Bedolach Y,Fink D,Kiderman A

    更新日期:2019-12-01 00:00:00