Needs and opportunities for achieving optimal outcomes from the use of medicines in hospitals and health systems

American Journal of Health-System Pharmacy

Volumn 68, Issue 12, 2011, Pages 1086-1096

  Brennan, Cynthia ^d   Donnelly, Kim ^a,b   Somani, Shabir ^b,c  

^a UNIVERSITY OF WASHINGTON MEDICAL CENTER   (United States)

^b U of WI School of Pharmacy   (United States)

^c UNIVERSITY OF WASHINGTON   (United States)

^d NONE

Author keywords

[No Author keywords available]

Indexed keywords

ACCREDITATION; ADVERSE DRUG REACTION; DRUG INDUSTRY; DRUG INFORMATION; DRUG MARKETING; DRUG USE; ECONOMIC ASPECT; FINANCIAL MANAGEMENT; FOOD AND DRUG ADMINISTRATION; GOVERNMENT REGULATION; HEALTH CARE ACCESS; HEALTH CARE MANPOWER; HEALTH CARE NEED; HEALTH CARE PERSONNEL; HEALTH CARE POLICY; HEALTH CARE SYSTEM; HOSPITAL CARE; HUMAN; HUMAN FACTORS RESEARCH; INFORMATION TECHNOLOGY; MEDICATION ERROR; ORGANIZATION; PATIENT EDUCATION; PATIENT PARTICIPATION; PATIENT SAFETY; PERFORMANCE MEASUREMENT SYSTEM; PRESCRIPTION; PRIORITY JOURNAL; REVIEW; RISK ASSESSMENT; RISK BENEFIT ANALYSIS; ROOT CAUSE ANALYSIS; TOTAL QUALITY MANAGEMENT; TREATMENT OUTCOME;

EID: 79959346125     PISSN: 10792082     EISSN: 15352900     Source Type: Journal    
DOI: 10.2146/ajhp110055     Document Type: Review

References (50)

1. Leape LL. The nature of adverse events in hospitalized patients. N Engl J Med. 1991; 324:377-84.
2. Bates DW, Boyle DL, Vander Vliet MB et al. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995; 10:199-205.
3. Ghandi TK, Weingart NS, Borus J et al. Adverse drug events in ambulatory care. N Engl J Med. 2003; 348:1556-64. (Pubitemid 36437933)
4. 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. (Pubitemid 36231621)
5. Gurwitz JH, Field TS, Harrold LR et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. J Am Med Assoc. 2003; 289:1107-16. (Pubitemid 37430324)
6. Aspden P, Wolcott JA, Bootman JL et al., eds. Preventing medication errors: quality chasm series. Washington DC:National Academies Press; 2006.
7. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington DC:National Academy Press; 1999.
8. Re-engineering the medication-use system: proceedings of a national interdisciplinary conference conducted by the Joint Commission of Pharmacy Practitioners. Am J Health-Syst Pharm. 2000; 57:537-601.
9. Avorn J. Powerful medicines: the benefits, risks and costs of prescription drugs. New York: First Vintage; 2005.
10. Food and Drug Administration. Promoting safe and effective drugs for 100 years. www.fda.gov/AboutFDA/WhatWeDo/History/ProductRegulation/ PromotingSafeandEffectiveDrugsfor100Years/default.htm (accessed 2011 Feb 22).
11. Food and Drug Administration. Food and Drug Administration Amendments Act (FDAAA) of 2007. www.fda.gov/RegulatoryInformation/Legislation/ federalfooddrugandcosmeticactfdcact/significantamendmentstothefdcact/ foodanddrugadministrationamendmentsactof2007/default.htm (accessed 2011 Feb 22).
12. Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. NCHS data brief, no 42. Hyattsville, MD: National Center for Health Statistics; 2010.
13. Qato DM, Alexander GC, Conti RM et al. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. J Am Med Assoc. 2008; 300:2867-78.
14. Forster AJ, Murff HJ, Peterson JF et al. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005; 20:317-23. (Pubitemid 40617599)
15. Unroe KT, Pfeiffenberger T, Riegelhaupt S et al. Inpatient medication reconciliation at admission and discharge: a retrospective cohort study of age and other risk factors for medication discrepancies. Am J Geriatr Pharmacother. 2010; 8:115-26.
16. Coleman EA, Smith JD, Raha D et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005; 165:1842-7. (Pubitemid 41352078)
17. ASHP guidelines on preventing medication errors in hospitals. In: Hawkins B, ed. Best practices for hospital and health-system pharmacy, 2010-2011 edition. Bethesda, MD: American Society of Health-System Pharmacists. 2010: 178-203.
18. Hennessy S. Potentially remediable features of the medication-use environment in the United States. Am J Health-Syst Pharm. 2000; 57:543-8. (Pubitemid 30353114)
19. Siska MH, Tribble DA. Opportunities and challenges related to technology in supporting optimal pharmacy practice models in hospitals and health systems. Am J Health-Syst Pharm. 2011; 68:e80-90.
20. U.S. Government Printing Office. Medicare Prescription Drug Improvement and Modernization Act of 2003. www.gpo.gov/fdsys/pkg/BILLS-108hr1enr/pdf/BILLS- 108hr1enr.pdf (accessed 2011 Feb 22).
21. DeNavas-Walt C, Proctor BD, Smith JC. U.S. Census Bureau, Current Population Reports, P60-238, Income, poverty, and health insurance coverage in the United States: 2009, U.S. Government Printing Office, Washington, DC; 2010.
22. U.S. Government Printing Office. Patient Protection and Affordable Care Act. http://democrats.senate.gov/reform/patient-protection-affordable-care-act- as-passed.pdf (accessed 2011 Feb 22).
23. American Hospital Association. 2010 health and hospital trends. www.aha.org/aha/research-and-trends/health-and-hospital-trends/2010.html (accessed 30 Sep 2010).
24. Association of Academic Health Centers. Out of order, out of time - the state of the nation's health workforce. www.aahcdc.org/Portals/0/pdf/AAHC- OutofTime-4WEB.pdf (accessed 30 Sep 2010).
25. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing and adverse drug reactions in United States hospitals. Pharmacotherapy. 2006; 26:735-47. (Pubitemid 43807625)
26. Pathways for Medication Safety. Tools. www.medpathways.info/medpathways/ tools/tools.html (accessed 2010 Aug 1).
27. Food and Drug Administration. Adverse Drug Event Reporting System (AERS). www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Surveillance/ AdverseDrugEffects/default.htm (accessed 2011 Feb 22).
28. Gosby J, Anderson T. Human factors engineering design demonstrations can enlighten your RCA team. Qual Saf Health Care 2003; 12:119-21. (Pubitemid 36458148)
29. Failure modes and effects analysis (FMEA) tool. www.ihi.org/IHI/Topics/ Improvement/ImprovementMethods/Tools/ Failure+Modes+and+Effects+Analysis+%28FMEA%29+Tool+%28IHI+Tool%29.htm (accessed 2010 Aug 30).
30. Department of Health and Human Services. Patient safety and quality improvement, 42 CFR 3. www.pso.ahrq.gov/regulations/fnlrule01.htm (accessed 2010 Jul 25).
31. Food and Drug Administration. Approved risk evaluation and mitigation strategies (REMS). www.fda.gov/Drugs/DrugSafety/ PostmarketDrugSafetyInformationforPatientsandProviders/ucm111350.htm (accessed 2010 Aug 1).
32. Baciu A, Stratton K, Burke SP, eds. Future of drug safety: promoting and protecting the health of the public. Washington, DC: National Academies Press; 2007.
33. Food and Drug Administration. Prescription Drug User Fee Act (PDUFA). www.fda.gov/forindustry/userfees/prescriptiondruguserfee/default.htm (accessed 2011 Feb 22).
34. Meyer BM. The Food and Drug Administration Amendments Act of 2007: drug safety and pharmacy implications: introduction. Am J Health-Syst Pharm. 2009; 66(suppl 7):S3-5.
35. American Society of Health-System Pharmacists. REMS database. www.ashp.org/Import/PRACTICEANDPOLICY/PracticeResourceCenters/REMSRDDS/ quickguide.aspx (accessed 2010 Aug 31).
36. Centers for Medicare and Medicaid Services. Conditions of participation. www.cms.gov/CFCsAndCoPs/ (accessed 2011 Feb 22).
37. American Society of Health-System Pharmacists. Residency accreditation. www.ashp.org/accreditation-residency (accessed 2010 Jul 25).
38. National Committee for Quality Assurance. Health Plan Employer Data and Information Set (HEDIS). www.ncqa.org/tabid/187/Default.aspx (accessed 2011 Feb 22).
39. Federal Register. Executive Order 13410 of August 22, 2006: Promoting quality and efficient health care in federal government administered or sponsored health care programs. http://edocket.access.gpo.gov/2006/pdf/06-7220. pdf (accessed 2011 Feb 22).
40. Hazelwood A, Cook E. Improving quality of health care through pay-for-performance programs. Health Care Manag. 2008; 27:104-12.
41. Schnipper JL, Kirwin JL, Cotugno MC et al. The role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006; 166:565-71.
42. The Joint Commission. Sentinel event. www.jointcommission.org/sentinel- event.aspx/ (accessed 2010 Aug 31).
43. Institute for Healthcare Improvement. SBAR technique for communication: a situational briefing model. www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm (accessed 2010 Aug 30).
44. Wickens CD, Lee JD, Liu Y et al. Introduction to human factors engineering. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 2004:4-7.
45. University of Wisconsin Center for Quality and Productivity Improvement. SEIPS model. http://cqpi.engr.wisc.edu/seips-model (accessed 2011 Feb 22).
46. Carayon P, Hundt AS, Karsh BT et al. Work system design for patient safety: the SEIPS model. Qual Safe Health Care. 2006; 15:50-8.
47. Lohr KN. Medicare: a strategy for quality assurance. Vol. 1. Washington, DC: National Academy Press; 1990:21.
48. American Society of Health-System Pharmacists. The ASHP discussion guide on the pharmacist's role in quality improvement. www.ashp.org/s-ashp/docs/files/ QII-DiscussionGuideQI.pdf (accessed 2010 Aug 1).
49. Institute for Healthcare Improvement. Improvement methods. www.IHI.org/Topics/Improvement/Improvementmethods/HowToImprove (accessed 2011 Mar 28).
50. Institute for Healthcare Improvement. Plan-Do-Study-Act (PDSA) worksheet. www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Plan-Do-Study- Act%20(PDSA)%20Worksheet.htm (accessed Aug 10 2010).