Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system

Quality and Safety in Health Care

Volumn 17, Issue 1, 2008, Pages 37-46

  Mills, P D ^a,d   Neily, J ^a   Kinney, L M ^a   Bagian, J ^b   Weeks, W B ^c  

^a VA National Center for Patient Safety Field Office   (United States)

^b VA National Center for Patient Safety   (United States)

^c VA MEDICAL CENTER   (United States)

^d NONE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ANESTHETIC AGENT; ANTIBIOTIC AGENT; ANTIDIABETIC AGENT; ANTINEOPLASTIC AGENT; ANTITHROMBOCYTIC AGENT; ANXIOLYTIC AGENT; CARDIOVASCULAR AGENT; HEPARIN; NARCOTIC AGENT; POTASSIUM; SEDATIVE AGENT; WARFARIN;

ARTICLE; CONTROLLED STUDY; HUMAN; LEADERSHIP; MEDICAL CARE; MEDICAL EDUCATION; MEDICATION ERROR; OUTCOME ASSESSMENT; PATIENT SAFETY; UNSPECIFIED SIDE EFFECT; VETERAN;

DRUG THERAPY; DRUG THERAPY, COMPUTER-ASSISTED; HEALTH PLAN IMPLEMENTATION; HEALTH SERVICES RESEARCH; HOSPITALS, VETERANS; HUMANS; MEDICATION ERRORS; MEDICATION SYSTEMS, HOSPITAL; ORGANIZATIONAL CULTURE; OUTCOME AND PROCESS ASSESSMENT (HEALTH CARE); TOTAL QUALITY MANAGEMENT; UNITED STATES;

EID: 39349117321     PISSN: 14753898     EISSN: None     Source Type: Journal    
DOI: 10.1136/qshc.2006.021816     Document Type: Article

References (44)

1. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84.
2. Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1997;277:301-6.
3. Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA 1990;263:2329-34.
4. Weeks WB, Waldron J, Foster T, et al. The organizational costs of preventable medical errors Jt Comm J Qual Improv 2001;27:533-9.
5. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997;277:307-11.
6. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43.
7. Cohen, MR. Causes of medication errors. In: Cohen MR, ed. Medication Errors. Washington, DC: American Pharmaceutical Association, 1999:1.1-1.8.
8. Institute of Medicine. Nursing: inseparably linked to patient safety. In: Page A, ed. Keeping patients safe: transforming the work environment of nurses. Washington, DC: The National Academies Press, 2004:23-52.
9. Reason J. Managing the risks of organizational accidents. Brookfield, VT: Ashgate Publishing Company, 1997.
10. Gosbee LL, Burkhardt ME. Application of human factors engineering in process and equipment design. In: Manasse HR, Thompson KK, eds. Medication safety: a guide for health care facilities. Bethesda, MD: Am Soc Health-System Pharm, 2005:201-26.
11. Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Informatics Assoc 1998;5:305-14.
12. Gandhi TK, Seger DL, Bates DW. Identifying drug safety issues: from research to practice. Int J Qual Health Care 2000;12:69-76.
13. Murff HJ, Patel VL, Hripcsak G, et al. Detecting adverse events for patient safety research: a review of current methodologies. J Biomed Inform 2003;36:131-43.
14. Welsh CH, Pedot R, Anderson RJ. Use of morning report to enhance adverse event detection. J Gen Intern Med 1996;11:454-60.
15. O'Neil AC, Petersen LA, Cook EF, et al. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med 1993;119:370-6.
16. Gandhi TK, Burstin HR, Cook EF, et al. Drug complications in outpatients. J Gen Intern Med 2000;15:149-54.
17. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138:161-7.
18. Davis K, Schoenbaum SC, Collins KS, et al. Room for improvement: patients reports on the quality of their health care. The Commonwealth Fund; 2002.
19. Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health-System Pharm 2002;59:436-46.
20. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-71.
21. Thomas EJ, Studdert DM, Brennan TA. The reliability of medical record review for estimating adverse event rates. Ann Intern Med 2002;136:812-6.
22. Bates DW, Evans RS, Murff H, et al. Detecting adverse events using information technology. J Am Med Inform Assoc 2003;10:115-28.
23. Seger AC, Gandhi TK, Hope C, et al. Development of a computerized adverse drug event (ADE) monitor in the outpatient setting. In: Henriksen K, Battles JB, Marks ES, et al, eds. Advances in patient safety: from research to implementation, Volume 2. Rockville, MD: Agency for Healthcare Research and Quality, 2005:CD.
24. Honigman B, Light P, Pulling RM, et al. A computerized method for identifying incidents associated with adverse drug events in outpatients. Int J Med Informatics 2001;61:21-32.
25. Grasela TH, Walawander CA, Kennedy DL, et al. Capability of hospital computer systems in performing drug-use evaluations and adverse drug event monitoring. Am J Hosp Pharm 1993;50:1889-95.
26. Levy M, Azaz-Livshits T, Sadan B, et al. Computerized surveillance of adverse drug reactions in hospital: implementation. Eur J Clin Pharm 1999;54:887-92.
27. Dormann H, Muth-Selbach U, Krebs S, et al. Incidence and costs of adverse drug reactions during hospitalisation. Drug Saf 2000;22:161-8.
28. Bagheri H, Michel F, Lapeyre-Mestre M, et al. Detection and incidence of drug-induced liver injuries in hospital: a prospective analysis from laboratory signals. Br J Clin Pharm 2000;50:479-84.
29. Whipple JK, Quebbeman EJ, Lewis KS, et al. Identification of patient-controlled analgesia overdoses in hospitalized patients: a computerized method of monitoring adverse events. Ann Pharm 1994;28:655-8.
30. Classen DC, Pestotnik SL, Evans RS, et al. Description of a computerized adverse drug event monitor using a hospital information system. Hosp Pharm 1992;27:774-83.
31. Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital patients. JAMA 1991;266:2847-51.
32. Brown S, Black K, Mrochek S, et al. RADARx: recognizing, assessing, and documenting adverse Rx events. AMIA Annu Symp Proc 2000:101-5.
33. Payne TH, Savarino J, Marshall R, et al. Use of a clinical event monitor to prevent and detect medication errors. AMIA Annu Symp Proc 2000:640-4.
34. Raschke RA, Gollihare B, Wunderlich TA, et al. A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital JAMA 1998;280:1317-20.
35. Honigman B, Lee J, Rothschild J, et al. Using computerized data to identity adverse drug events in outpatients. J Am Med Informatics Assoc 2001;8:254-66.
36. Wald H, Shojania KG. Root cause analysis. In: Shojania KG, Duncan BW, McDonald KM, et al, eds. Making health care safer: a critical analysis of patient safety practices. Rockville, MD: Agency for Healthcare Research and Quality, 2001:51-6.
37. Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Policy and Procedures, 2005. Available at: http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/ (accessed 17 April 2006).
38. Bagian JP, Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001;27:522-32.
39. Neily J, Ogrinc G, Mills PD, et al. Using aggregate root cause analysis to improve patient safety. Jt Comm J Qual Improv 2003;29:434-9.
40. Weeks WB, Bagian JP. Developing a culture of safety in the Veterans Health Administration. Eff Clin Pract 2000;3:270-76.
41. VA National Center for Patient Safety. Glossary of patient safety terms, 2006. Available at: http://www.patientsafety.gov/glossary.html (accessed 19 April 2006).
42. Mills PD, Neily J, Luan D, et al. Using aggregate root cause analysis to reduce falls and related injuries. Jt Comm J Qual Improv 2005;31:21-31.
43. Mills PD, Neily J, Luan D, et al. Actions and implementation strategies to reduce suicidal events in the VHA. Jt Comm J Qual Safety 2006;32:130-41.
44. Institute for Safe Medication Practices. High alert medication list. Available at: http://www.ismp.org/Tools/highalertmedications.pdf (accessed 14 July 2006).