Assessing the state of safe medication practices using the ISMP medication safety self assessment® for hospitals: 2000 and 2011

Joint Commission Journal on Quality and Patient Safety

Volumn 40, Issue 2, 2014, Pages 51-67

  Vaida, Allen J ^a   Smetzer, Judy L ^d   Lamis, Rebecca L ^b   Cohen, Michael R ^b   Kenward, Kevin ^c  

^a INSTITUTE FOR SAFE MEDICATION PRACTICES   (United States)

^b ISMP   (United States)

^c AMERICAN HOSPITAL ASSOCIATION   (United States)

^d NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; ELECTRONIC PRESCRIBING; HEALTH CARE QUALITY; HOSPITAL ORGANIZATION; IN SERVICE TRAINING; INTERPERSONAL COMMUNICATION; MEDICATION ERROR; ORGANIZATION; ORGANIZATION AND MANAGEMENT; PATIENT EDUCATION; PATIENT SAFETY; SAFETY; UNITED STATES;

COMMUNICATION; ELECTRONIC PRESCRIBING; INSERVICE TRAINING; MEDICATION ERRORS; MEDICATION SYSTEMS, HOSPITAL; ORGANIZATIONAL CULTURE; PATIENT EDUCATION AS TOPIC; PATIENT SAFETY; QUALITY OF HEALTH CARE; SAFETY MANAGEMENT; UNITED STATES;

EID: 84893027749     PISSN: 15537250     EISSN: None     Source Type: Journal    
DOI: 10.1016/s1553-7250(14)40007-2     Document Type: Article

References (83)

1. Kaiser Family Foundation. State Health Facts: Retail Prescription Drugs Filled at Pharmacies (Annual per Capita), 2011. Source: SDI Health, LLC: Special Data Request, 2012. Accessed Jan 7, 2014. http://www.statehealthfacts.org/ comparemaptable.jsp?ind=267&cat=54.
2. Committee on Identifying and Preventing Medication Errors, Institute of Medicine. Preventing Medication Errors. Washington, DC: National Academies Press, 2007.
3. US Food and Drug Administration (FDA). Medication Error Reports. 2009. Accessed Jan 9, 2014. (Updated: Mar 5, 2009.) http://www.fda.gov/Drugs/ DrugSafety/MedicationErrors/ucm080629.htm.
4. Wertheimer AI, Santella TM. Medication compliance research: Still so far to go. J Appl Res Clin Exp Ther. 2003;3(3):254-261.
5. Kohn LT, Corrigan JM, Donaldson MS, editors; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Better Health System. Washington, DC: National Academy Press, 2000.
6. Smetzer JL, et al. Findings from the ISMP Medication Safety Self-Assessment ® for Hospitals. Jt Comm J Qual Saf. 2003;29(11):586-597.
7. Lesar T, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-226.
8. Lesar TS, et al. The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives. Jt Comm J Qual Patient Saf. 2007;33(2):73-82.
9. Kazandjian VA, et al. Enhancing medication use safety: Benefits of learning from your peers. Qual Saf Health Care. 2009;18(5):331-335.
10. Chuang MH, et al. Southern Taiwan findings from the Institute for Safe Medication Practices Medication Safety Self Assessment for Hospitals Survey. Tzu Chi Medical Journal. 2007;19(2:74-83. Accessed Jan 7, 2014. http://www.tzuchi.com.tw/file/tcmj/2007-v19n2/19-2-74-83.pdf.
11. Greenall J, U D, Lam R. An effective tool to enhance a culture of patient safety and assess the risks of medication use systems. Healthc Q. 2005; 8 Spec No:53-58.
12. Hofman L, et al. Assessment of risk in medication-use systems: Learning from the Medication Safety Self-Assessment. Can J Hosp Pharm. 2007; 60(1):49-52.
13. Otero López MJ, et al. Evaluación de las prácticas de seguridad de los sistemas de utilización de medicamentos en los hospitales españoles (2007). Med Clin (Barc). 2008;131 Suppl 3:39-47.
14. Padilla-Marín V, et al. Cuestionario ISMP-España y estrategia de mejora en el uso seguro del medicamento dentro del Servicio Andaluz de Salud. Farm Hosp. 2012;36(5):374-384.
15. Institute for Safe Medication Practices Canada. Medication Safety Self-Assessment ® for Hospitals (Canadian Version II). Accessed Jan 7, 2014. http://www.ismp-canada.org/hmssa/.
16. Institute for Safe Medication Practices España. Cuestionario de autoevaluación de la eguridad del sistema de utilización de los medicamentos en los hospitales. 2007. Accessed Jan 7, 2014. http://www.ismp- espana.org/ficheros/cuestionario.pdf.
17. Clinical Excellence Commission, New South Wales Therapeutic Advisory Group. Medication Safety Self Assessment® for Australian Hospitals. 2007. Accessed Jan 7, 2014. https://mssa.cec.health.nsw.gov.au/MSSA-introduction.html.
18. Institute for Safe Medication Practices (ISMP). Preliminary Comparative Data from the 2004 ISMP Medication Safety Self Assessment® for Hospitals: A Quality Improvement Workbook for Study Participants. Horshom, PA: ISMP, 2004. Accessed Jan 7, 2014. http://www.ismp.org/selfassessments/Hospital/ ismpworkbooksfinal.pdf.
19. The Joint Commission. Facts About the National Patient Safety Goals. Jun 26, 2013. Accessed Jan 7, 2014. http://www.jointcommission.org/standards- information/npsgs.aspx.
20. The Joint Commission. 2014 Comprehensive Accreditation Manual for Hospitals:, The Official Handbook. Oak Brook, IL: Joint Commission Resources, 2013.
21. World Health Organization, World Alliance for Patient Safety. WHO Surgical Safety Checklist and Implementation Manual. 2008. Accessed Jan 7, 2014. http://www.who.int/patientsafety/safesurgery/ss-checklist/en/index.html.
22. Agency for Healthcare Research and Quality. Team STEPPS®: National Implementation. Accessed Jan 7, 2014. http://teamstepps.ahrq.gov/.
23. Institute for Safe Medication Practices. ISMP Statement on Use of Metric Measurements to Prevent Errors with Oral Liquids. Oct 2011. Accessed Jan 7, 2014. http://www.ismp.org/pressroom/PR20110808.pdf.
24. Institute for Safe Medication Practices. High-alert medication feature: Reducing patient harm from opiates. ISMP Medication Safety Alert! 2007 Feb 22;12(4):1-3.
25. Institute for Safe Medication Practices. Just Culture and its critical link to patient safety (Part 1). ISMP Medication Safety Alert! 2012 May 17;17(10):1-4.
26. Institute for Safe Medication Practices. Plain D5W or hypotonic saline solutions post-op could result in acute hyponatremia and death in healthy children. ISMP Medication Safety Alert! 2009 Aug 13;14(16):1-4.
27. Institute for Safe Medication Practices (ISMP). 2011 ISMP Medication Safety Self Assessment® for Hospitals. Horsham, PA: ISMP, 2011. Accessed Jan 7, 2014. http://www.ismp.org/selfassessments/Hospital/2011/full.pdf.
28. Boone HN, Boone DA. Analyzing Likert data. Journal of Extension. 2012;50(2): online journal. Accessed Jan 7, 2014. http://www.joe.org/joe/ 2012april/tt2.php.
29. Allen IE, Seaman CA. Statistics Roundtable: Likert scales and data analysis. Quality Progress. Jul 2007. Accessed Jan 7, 2014.http://asq.org/ qualityprogress/2007/07/statistics/likert-scales-and-data-analyses.html.
30. Jaccard J, Wan CK. LISREL Approaches to Interaction Effects in Multiple Regression. Thousand Oaks, CA: Sage Publications, 1996.
31. Marill KA. Advanced statistics: Linear regression, part I: Simple linear regression. Acad Emerg Med. 2004;11(1):87-93.
32. Health Forum, LLC. Annual Survey Database, 2010. Chicago: American Hospital Association, 2011.
33. The Joint Commission. Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012. Oak Brook, IL, 2012. Accessed Jan 7, 2014. http://www.jointcommission.org/improving-americas- hospitals-joint-commission-annual-report-quality-safety-2012/.
34. Wachter RM. The end of the beginning: Patient safety five years after 'To Err Is Human.' Health Aff (Millwood). 2004; Suppl Web Exclusives:W4-534-545.
35. Leape LL, Berwick DM. Five years after To Err Is Human: What have we learned? JAMA. 2005 May 18;293(19):2384-2390.
36. Jewell K, Mc Giffert L. To Err Is Human To Delay Is Deadly. Austin, TX: Consumers Union, 2009. Accessed Jan 7, 2014. http://safepatientproject.org/ safepatientproject.org/pdf/safepatientproject.org-ToDelayIsDeadly.pdf.
37. Health Grades. The Sixth Annual Health Grades Patient Safety in American Hospitals Study. Golden, CO: Health Grades, 2009. Accessed Jan 8, 2014. http://www.psnet.ahrq.gov/resource.aspx?resourceID=9932.
38. Leape L, et al. Transforming healthcare: A safety imperative. Qual Saf Health Care. 2009;18(6):424-428.
39. Wachter RM. Patient safety at ten: Unmistakable progress, troubling gaps. Health Aff (Millwood). 2010;29(1:165-173. Accessed Jan 8, 2014. http://content.healthaffairs.org/content/29/1/165.full.
40. Clark C. 10 years after To Err Is Human: Are hospitals safer? Health Leaders Media. Nov 30, 2009. Accessed Jan 8, 2014. http://www. healthleadersmedia.com/content/QUA-242686/10-Years-After-To-Err-is-Human-Are- Hospitals-Safer.html.
41. Lesar T, et al. Using the ISMP Medication Safety Self-Assessment to improve the medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-226.
42. Mc Kinney M. About that quality chasm. Modern Healthcare.com. Feb 21, 2011. Accessed Jan 8, 2014. http://www.modernhealthcare.com/article/20110221/ MAGAZINE/110219950.
43. Centers for Medicare & Medicaid Services. EHR Incentive Programs: The Official Web Site for the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs. (Updated: Jan 14, 2014.) Accessed Jan 15, 2014. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ index.html?redirect=/ehrincentiveprograms/.
44. Moran J, Scanlon D. Slow progress on meeting hospital safety standards: Learning from the Leapfrog Group's efforts. Health Aff (Millwood). 2013;32(1):27-35.
45. The Joint Commission. Facts About Speak Up™ Initiatives. (Updated: Nov 25, 2013.) Accessed Jan 8, 2014. http://www.jointcommission.org/facts-about- speak-up-initiatives/.
46. National Patient Safety Foundation, Patient and Family Advisory Council. National Agenda for Action: Patients and Families in Patient Safety: Nothing About Me, Without Me. 2008. Accessed Jan 15, 2014. http://www.npsf.org/wp- content/uploads/2011/10/Nothing-About-Me.pdf.
47. Delbanco T, et al. Healthcare in a land called People Power: Nothing about me without me. Heath Expect. 2001;4(3):144-150.
48. Barry MJ, Edgman-Levitan S. Shared decision making Pinnacle of patient-centered care. N Engl J Med. 2012 Mar 1; 366(9):780-781.
49. Institute for Safe Medication Practices. Consumer Med Safety.org. Accessed Jan 8, 2014. http://www.consumermedsafety.org/.
50. Agency for Healthcare Research and Quality. Questions Are the Answer. Accessed Jan 8, 2014. http://www.ahrq.gov/legacy/questions/.
51. Centers for Medicare & Medicaid Services. Hospital Compare. (Updated: Dec 23, 2013.) Accessed Jan 8, 2014. http://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalCompare. html.
52. Josie King Foundation. Foundation Programs: Condition Help (Condition H). 2012. Accessed Jan 8, 2014. http://www.josieking.org/conditionh.
53. Institute for Safe Medication Practices. Rapid response team activation by patients can mitigate errors. ISMP Medication Safety Alert! 2006;11(11):1-2.
54. Institute for Safe Medication Practices. The 9th annual ISMP Cheers Awards: And the winners are ISMP Medication Safety Alert! 2006;11(25):1-3.
55. Mc Cannon CJ, Hackbarth AD, Griffith FA. Miles to go: an introduction to the 5 Million Lives Campaign. Jt Comm J Qual Patient Saf. 2007;33(8):477-484.
56. Clarke S. Perceptions of organisational safety: Implications for the development of safety culture. J Organ Behav. 1999;20(2):185-198.
57. Randell R. Medicine and aviation: A review of the comparison. Methods Inf Med. 2003;42(4):433-436.
58. Zohar D. Safety climate in industrial organizations: Theoretical and applied implications. J Appl Psychol. 1980; 65(1):96-102.
59. Carroll JS, Rudolph JW, Hatakenaka S. Lessons learned from non-medical industries: Root cause analysis as cultural change at a chemical plant. Qual Saf Health Care. 2002;11(3):266-279.
60. Scott T, et al. Does organisational culture influence health care performance? J Health Serv Res Policy. 2003;8(2):105-117.
61. Wakefield JG, et al. Patient safety culture: Factors that influence clinician involvement in patient safety behaviours. Qual Saf Health Care. 2010;19 (6):585-591.
62. Gherardi S, Nicolini D. The organizational learning of safety in communities of practice. Journal of Management Inquiry. 2000;9(1):7-18.
63. Institute for Safe Medication Practices. Press Release: Organizations Release New Tools for Reducing Medication Errors. Dec 10, 2002. Accessed Jan 8, 2014. http://www.ismp.org/Tools/pathways.asp.
64. Agency for Healthcare Research and Quality. Surveys on Patient Safety Culture. Nov 2013. Accessed Jan 8, 2014. http://www.ahrq.gov/professionals/ quality-patient-safety/patientsafetyculture/index.html
65. Medically Induced Trauma Support Services. Home page. Accessed Jan 8, 2014. http://mitss.org/.
66. Texas Medical Institute of Technology. Safety Leaders. ® Accessed Jan 8, 2014. http://www.safetyleaders.org/home.jsp.
67. Wolf ZR. Health care providers' experiences with making fatal medication errors. In Cohen MR, editor: Medication Errors, 2nd ed. Washington, DC: American Pharmacists Association: 2007, 43-51.
68. Scott SD, Hirschinger LE, Cox KR. Sharing the load: Rescuing the healer after trauma. RN. 2008;71(12):38-40, 42-43.
69. Scott SD, et al. Caring for our own: Deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36(5):233-240.
70. Denham C. TRUST: The 5 rights of the second victim. J Patient Saf. 2007;3(2):107-119.
71. Conway J, et al. Respectful Management of Serious Clinical Adverse Events, 2nd ed. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement, 2011. (Available on www.IHI.org.)
72. Latter C. And justice for all. Prevention Strategist. 2009;2(4:46-53. Accessed Jan 8, 2014. http://legacy.justculture.org/media/Prevention-Strategist- Justice-For-All.pdf.
73. Leape LL. Full disclosure and apology: An idea whose time has come. Physician Exec. 2006;32(2):16-18.
74. The Joint Commission. New safety and error reduction standards for hospitals. Jt Comm Perspect. 21(2):1, 3.
75. Emanuel LL, et al., editors: The Patient Safety Education Project (PSEP) Core Curriculum. Chicago: PSEP Project, 2008, M7-14.
76. Agency for Healthcare Research and Quality. Patient Safety Primers: Medication Errors. (Updated: Oct 2012.) Accessed Jan 8, 2014. http://psnet.ahrq.gov/primer.aspx?primerID=2.
77. Tabler NG. Should physicians apologize for medical errors? Health Lawyer. 2007;19(3):23-26.
78. Wojcieszak D, Banja J, Houk C. The Sorry Works! Coalition: Making the case for full disclosure. Jt Comm J Qual Patient Saf. 2006;32(6):344-350.
79. National Quality Forum (NQF). Safe Practices for Better Healthcare 2010 Update: A Consensus Report. Washington, DC: NQF, 2010. Accessed Jan 8, 2014. http://www.qualityforum.org/Publications/2010/04/Safe-Practices-for-Better- Healthcare-%E2%80%93-2010-Update.aspx.
80. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. New York City: Back Bay Books, 2002.
81. Centers for Medicare & Medicaid Services. About the Partnership: Hospital Engagement Networks. Accessed Jan 8, 2014. http:// partnershipforpatients.cms.gov/about-thepartnership/hospital-engagement- networks/thehospitalengagementnetworks.html.
82. Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates, 1988.
83. Tavakol M, Dennick R. Making sense of Cronbach's alpha. Int J Med Educ. 2011;2:53-55. Accessed Jan 8, 2014. http://www.ijme.net/archive/2/cronbachs- alpha.pdf.