Medication errors associated with anticoagulant therapy in the hospital.

Anticoagulation in hospitalized patients is frequently associated with medication errors. To determine the extent and severity of this problem, we reviewed consecutively reported, anticoagulation-related medication errors over a 3-year period. We identified 130 medication errors.

Creating an integrated patient safety team.

Unlabelled: CREATING A PATIENT SAFETY TEAM: In May 2001 Brigham and Women's Hospital (Boston) created the Patient Safety Team, which was incorporated into the pre-existing safety and quality infrastructure. ESTABLISHING THE PATIENT SAFETY TEAM'S GOALS AND INITIATIVES: The goal was to create the safest possible environment for patients and staff by creating a culture of safety, increasing the capacity to measure and evaluate processes, committing to change unsafe processes, and adopting new technologies. To achieve this mission, the following initiatives were established: create a culture of safety, increase event identification, improve event analysis, close the feedback loop, assess risk proactively, improve medication safety, and involve the patient.