In this section :
- Hospital harm is everyone鈥檚 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
-
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
- Medication Incidents: Introduction
- Obstetric Hemorrhage: Introduction
- Patient Trauma: Introduction
- Pneumonia: Introduction
- Pneumothorax: Introduction
-
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
-
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
-
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
-
Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Introduction
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Discharge Abstract Database
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Importance to Patients and Families
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Clinical and System Reviews, Incident Analyses
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Measures
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Success Stories
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): References
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Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Introduction
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Discharge Abstract Database
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Importance to Patients and Families
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Clinical and System Reviews, Incident Analyses
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Measures
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Success Stories
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): References
- Birth Trauma: Introduction
- Device Failure: Introduction
-
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
-
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: References
Accreditation Canada, Canadian Institute for Health Information, Canadian Patient Safety Institute, Institute for Safe Medication Practices Canada.听Medication reconciliation in Canada: Raising the bar. Progress to date and the course ahead.听Ottawa, ON: Accreditation Canada; 2012.听
Alex S, Adenew AB, Arundel C, Maron DD, Kerns JC. Medication errors despite using electronic health records: The value of a clinical pharmacist service in reducing discharge-related medication errors.听Qual Manag Health Care.听2016; 25 (1): 32鈥�37. doi: 10.1097/QMH.0000000000000080.
Aspden P, Wolcott J, Bootman JL, Cronenwett LR. Preventing medication errors.听Quality chasm series. Institute of Medicine; 2006.听
Baker GR, Norton PG, Flintoft V, et al. The Canadian adverse events study: The incidence of adverse events among hospitalized patients in Canada.听CMAJ.听2004; 170 (11): 1678-1686.听
Bell CM, Brener SS, Gunraj N, Huo C, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases.听JAMA. 2011; 306 (8): 840-847. doi: 10.1001/jama.2011.1206.听
Bishop MA, Cohen BA, Billings LK, Thomas EV. Reducing errors through discharge medication reconciliation by pharmacy services.听Am J Health Syst Pharm.听2015; 72 (17 Suppl 2): S120-S16. doi: 10.2146/sp150021.
Boockvar KS, Blum S, Kugler A, et al. Effect of admission medication reconciliation on adverse drug events from admission medication changes.听Arch Intern Med.听2011; 171 (9): 860-861. doi: 10.1001/archinternmed.2011.163.听
Canadian Patient Safety Institute. Never Events for Hospital Care in Canada Safer Care for Patients. 2015.
Canadian Patient Safety Institute.听Implementing MedRec at Horizon Health Network. 2015. https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Implementing-MedRec-at-Horizon-Health-Network.aspx听
Eggink RN, Lenderink AW, Widdershoven JWMG, van den Bemt PMLA. The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure.听Pharm World Sci.听2010; 32 (6): 759-766. doi: 10.1007/s11096-010-9433-6.听
Health Standards Organization (HS0). Leading Practices Hamilton Health Sciences Toolkit for Safe Implementation of Insulin Pens. Health Standards Organization; 2012. 听
Institute for Safe Medication Practices (ISMP). ISMP list of high-alert medications in acute care settings.听ISMP; 2011.听
ISMP Canada.听Definitions of terms. 2016.听
Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events: ADE prevention study group.听JAMA.听1995; 274 (1): 35-43.
Lee JY, Leblanc K, Fernandes OA, Huh JH, et al. Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.听Ann Pharmacother. 2010 Dec;44(12):1887-95.
Mekonned AB, McLachlan AJ, Brien JE. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis.听BMJ Open.听2016; 6 (2): e010003. doi: 10.1136/bmjopen-2015-010003.听
Michels RD, Meisel SB. Program using pharmacy technicians to obtain medication histories.听Am J Health-Sys Pharm.听2003; 60 (19): 1982-1986.
Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Standardization as a mechanism to improve safety in health care.听Jt Comm J Qual Saf. 2004; 30 (1): 5-14.
Safer Healthcare Now! Medication Reconciliation Getting Started Kit. Canadian Patient Safety Institute; 2017.
Scales DC, Fischer HD, Li P, et al. Unintentional continuation of medications intended for acute illness after hospital discharge: A population-based cohort study.听J Gen Intern Med.听2016; 31 (2): 196-202. doi: 10.1007/s11606-015-3501-5.
Vira T, Colquhoun M, Etchells EE. Reconcilable differences: correcting medication errors at hospital admission and discharge.听Qual Saf Health Care. 2006; 15 (2): 122-126.听
Whittington J, Cohen H. OSF healthcare's journey in patient safety.听Qual Manag Health Care.听2004; 13 (1): 53-59.
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Medication Incidents
