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Post-marketing surveillance is a critical component of pharmaceutical regulation, often uncovering unanticipated adverse drug reactions (ADRs) once a drug is widely used over an extended period.
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Related Experiment Video

Updated: Jul 24, 2025

Implementation of a Real-Time Psychosis Risk Detection and Alerting System Based on Electronic Health Records using CogStack
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Operationalizing a Medication Safety Gap Assessment for a Large Health System.

Carley Warren1, Joan Kramer1,2, L Hayley Burgess1,2

  • 1Clinical Services Group, HCA Healthcare, Nashville, TN.

HCA Healthcare Journal of Medicine
|July 10, 2023
PubMed
Summary
This summary is machine-generated.

Medication errors cause thousands of deaths annually. A 9-month assessment revealed that while some safety practices are widely adopted, many acute care facilities struggle with full implementation, highlighting a need for continued improvement in medication safety.

Keywords:
drug use errorsmedication errorsmedication managementmedication safetymedication therapy managementpatient care managementpatient safetysafe medication use

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Area of Science:

  • Patient Safety
  • Healthcare Quality Improvement
  • Medication Management

Background:

  • Medication errors are a significant cause of preventable harm and mortality in the US.
  • The Institute for Safe Medication Practices (ISMP) has developed best practices to mitigate medication errors since 2014.

Purpose of the Study:

  • To assess the implementation status of ISMP Targeted Medication Safety Best Practices (TMSBP) in acute care facilities.
  • To identify gaps in the adoption of medication safety best practices.

Main Methods:

  • A 9-month assessment utilizing tools to evaluate current practices against ISMP TMSBP.
  • Data collection from 121 acute care facilities on the implementation of selected best practices.

Main Results:

  • 8 medication safety practices were not implemented by over 20 hospitals.
  • 9 practices were fully implemented by more than 80 hospitals.
  • Varied levels of adoption indicate room for improvement across facilities.

Conclusions:

  • Full implementation of medication safety best practices is resource-intensive and requires strong leadership.
  • Opportunities exist to enhance medication safety in US acute care facilities through continued focus on ISMP TMSBP.