In this section :
- Hospital harm is everyone’s concern
-
Hospital Harm Improvement Resource
- How to Use the Hospital Harm Measure for Improvement
- Learning from Harm
- General Patient Safety Quality Improvement and Measurement Resources
- Hypoglycemia: Introduction
- Aspiration Pneumonia: Introduction
- Delirium: Introduction
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Infusion, Transfusion and Injection Complications: Introduction
- Infusion, Transfusion and Injection Complications: Discharge Abstract Database
- Infusion, Transfusion and Injection Complications: Importance to Patients and Families
- Infusion, Transfusion and Injection Complications: Clinical and System Reviews, Incident Analyses
- Infusion, Transfusion and Injection Complications: Measures
- Infusion, Transfusion and Injection Complications: Success Stories
- Infusion, Transfusion and Injection Complications: References
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Medication Incidents: Introduction
- Medication Incidents: Discharge Abstract Database
- Medication Incidents: Importance to Patients and Families
- Medication Incidents: Clinical and System Reviews, Incident Analyses
- Medication Incidents: Measures
- Medication Incidents Prevention Success Stories
- Medication Incidents: References
- Obstetric Hemorrhage: Introduction
- Patient Trauma: Introduction
- Pneumonia: Introduction
- Pneumothorax: Introduction
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Post Procedural Infections: Introduction
- Post Procedural Infections: Discharge Abstract Database
- Post Procedural Infections: Importance to Patients and Families
- Post Procedural Infections: Clinical and Systems Reviews, Incident Analyses
- Post Procedural Infections: Measures
- Post Procedural Infections: Success Stories
- Post Procedural Infections: References
- Pressure Ulcer: Introduction
- Sepsis: Introduction
- UTI: Introduction
- Venous Thromboembolism: Introduction
- Wound Disruption: Introduction
- Obstetric Trauma: Introduction
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Procedure-Associated Shock: Introduction
- Procedure-Associated Shock: Discharge Abstract Database
- Procedure-Associated Shock: Importance to Patients and Families
- Procedure-Associated Shock: Clinical and System Review, Incident Analysis
- Procedure-Associated Shock: Measures
- Procedure-Associated Shock: Success Stories
- Procedure-Associated Shock: References
- Selected Serious Events: Introduction
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Electrolyte and Fluid Imbalance: Introduction
- Electrolyte and Fluid Imbalance: Discharge Abstract Database
- Electrolyte and Fluid Imbalance: Importance to Patients and Families
- Electrolyte and Fluid Imbalance: Clinical and System Reviews, Incident Analyses
- Electrolyte and Fluid Imbalance: Measures
- Electrolyte and Fluid Imbalance: Success Stories
- Electrolyte and Fluid Imbalance: References
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Anemia – Hemorrhage (Health Care / Medication Associated Condition): Introduction
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Discharge Abstract Database
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Importance to Patients and Families
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Clinical and System Reviews, Incident Analyses
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Measures
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Success Stories
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): References
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Anemia – Hemorrhage (Procedure-Associated Conditions): Introduction
- Anemia – Hemorrhage (Procedure-Associated Conditions): Discharge Abstract Database
- Anemia – Hemorrhage (Procedure-Associated Conditions): Importance to Patients and Families
- Anemia – Hemorrhage (Procedure-Associated Conditions): Clinical and System Reviews, Incident Analyses
- Anemia – Hemorrhage (Procedure-Associated Conditions): Measures
- Anemia – Hemorrhage (Procedure-Associated Conditions): Success Stories
- Anemia – Hemorrhage (Procedure-Associated Conditions): References
- Birth Trauma: Introduction
- Device Failure: Introduction
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Infections due to Clostridium difficile, MRSA or VRE: Introduction
- Infections due to Clostridium difficile, MRSA or VRE: Discharge Abstract Database
- Infections due to Clostridium difficile, MRSA or VRE: Importance to Patients and Families
- Infections due to Clostridium difficile, MRSA or VRE: Surveillance, Outbreak Management
- Infections due to Clostridium difficile, MRSA or VRE: Clinical and System Reviews, Incident Analyses
- Infections due to Clostridium difficile, MRSA or VRE: Measures
- Infections due to Clostridium difficile, MRSA or VRE: Success Stories
- Infections due to Clostridium difficile, MRSA or VRE: References
- Laceration: Introduction
- Retained Foreign Body: Introduction
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Viral Gastroenteritis: Introduction
- Viral Gastroenteritis: Discharge Abstract Database
- Viral Gastroenteritis: Importance to Patients and Families
- Viral Gastroenteritis: Surveillance, Outbreak Management
- Viral Gastroenteritis: Clinical and System Reviews, Incident Analyses
- Viral Gastroenteritis: Measures
- Viral Gastroenteritis: Success Stories
- Viral Gastroenteritis: References
Medication Incidents: Clinical and System Reviews, Incident Analyses
Given the broad range of potential causes of medication incidents, clinical and system reviews should be conducted to identify potential causes and determine appropriate recommendations.
Occurrences of harm are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types and frequency of these occurrences.
- Use appropriate analytical methods to understand the contributing factors.
- Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
- Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resources Introduction.
If your review reveals that your medication incidents are linked to specific processes, you may find these resources helpful:
- Institute for Healthcare Improvement (IHI). www.ihi.org
- How-to Guide: Prevent harm from high-alert medications. 2012. http://www.ihi.org/resources/Pages/Tools/
HowtoGuidePreventHarmfromHighAlertMedications.aspx - Institute for Healthcare Improvement (IHI). How-to Guide: Prevent harm from high-alert medications — pediatric supplement. http://www.ihi.org/resources/Pages/Tools/
HowtoGuidePreventHarmfromHighAlertMedicationsPediatricSupplement.aspx - Institute for Healthcare Improvement (IHI). How-to Guide: Prevent harm from high-alert medications — rural hospitals supplement. 2008. http://www.ihi.org/resources/pages/tools/
howtoguidepreventharmfromhighalertmedicationsruralhospitalssupplement.aspx - Improve core processes for administering medications. 2020. http://www.ihi.org/resources/Pages/Changes/
ImproveCoreProcessesforAdministeringMedications.aspx - Improve core processes for dispensing medications. 2020. http://www.ihi.org/resources/Pages/Changes/
ImproveCoreProcessesforDispensingMedications.aspx - Improve core processes for ordering medications. 2020. http://www.ihi.org/resources/Pages/Changes/
ImproveCoreProcessesforOrderingMedications.aspx
- How-to Guide: Prevent harm from high-alert medications. 2012. http://www.ihi.org/resources/Pages/Tools/
- Institute for Safe Medication Practices Canada. https://www.ismp-canada.org/
- Cross County MedRec Check-up. https://www.ismp-canada.org/medrec/map/
- ISMP list of high-alert medications in acute care settings. 2018. http://ismp.org/Tools/highalertmedications.pdf
- Medication safety self-assessment (MSSA). https://www.ismp-canada.org/mssa.htm
- The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) https://www.nccmerp.org/
- National Institute for Health and Care Excellence (NICE) https://www.nice.org.uk
- Medicines and Prescribing Centre. NICE guidelines: Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. http://www.nice.org.uk/guidance/NG5/
Medication Incidents
