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ALMUT G. WINTERSTEIN, PH.D., is Assistant Professor; and ABRAHAM G. HARTZEMA, PHARM.D., PH.D., is Professor and Eminent Scholar, Department of Pharmacy Health Care Administration, College of Pharmacy, University of Florida (UF), Gainesville. THOMAS E. JOHNS, PHARM.D., BCPS, is Assistant Director, Inpatient Pharmacy Services, Shands at the University of Florida, Gainesville. JESSICA M. DE LEON, PH.D., is Coordinator, Research Programs and Services, Department of Pharmacy Health Care Administration, College of Pharmacy, UF. KATHIE MCDONALD, R.N., M.P.H., is Nurse Epidemiologist, and ZAK HENSHAW, M.H.A., M.P.H., M.L.I.S., is Strategic Planner, Florida Medical Quality Assurance, Inc., Tampa. ROBERT PANNELL, M.S.P., is Coordinator, Florida Critical Access Hospital Program, Florida Department of Health, Office of Rural Health, Tallahassee.

Address correspondence to Dr. Winterstein at the Department of Pharmacy Health Care Administration, College of Pharmacy, University of Florida, P.O. Box 100496, Gainesville, FL 32610-0496 (almut{at}cop.ufl.edu).

Purpose. The medication safety infrastructure of critical-access hospitals (CAHs) in Florida was evaluated. Methods. Qualitative assessments, including a self-administered survey and site visits, were conducted in seven of nine CAHs between January and June 2003. The survey consisted of the Institute for Safe Medication Practices Medication Safety Self-assessment, the 2003 Joint Commission on Accreditation of Healthcare Organizations patient safety goals, health information technology (HIT) questions, and medication-use-process flow charts. Onsite visits included interviews of CAH personnel who had safety responsibility and inspections of pharmacy facilities. The findings were compiled into a matrix reflecting structural and procedural components of the CAH medication safety infrastructure. Results. The nine characteristics that emerged as targets for quality improvement (QI) were medication accessibility and storage, sterile product compounding, access to drug information, access to and utilization of patient information in medication order review, advanced safety technology, drug formularies and standardized medication protocols, safety culture, and medication reconciliation. Conclusion. Based on weighted importance and feasibility, QI efforts in CAHs should focus on enhancing medication order review systems, standardizing procedures for handling high-risk medications, promoting an appropriate safety culture, involvement in seamless care, and investment in HIT. Index terms: Compounding; Data collection; Drug information; Drug use; Errors, medication; Formularies; Hospitals; Medication orders; Patient information; Protocols; Quality assurance; Sterile products; Storage; Technology; Toxicity