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The Collection
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Quality and Safety Professionals
PATIENT SAFETY PRIMERS
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Setting of Care
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STUDY
Repeat medication errors in nursing homes: contributing factors and their association with patient harm.
Crespin DJ, Modi AV, Wei D, et al. Am J Geriatr Pharmacother. 2010;8:258-270.
STUDY
Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.
Field TS, Tjia J, Mazor KM, et al. Am J Med. 2011;124:179.e1-179.e7.
STUDY
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.
STUDY
Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.
Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.
REVIEW
Epidemiology of medication-related adverse events in nursing homes.
Handler SM, Wright RM, Ruby CM, Hanlon JT. Am J Geriatr Pharmacother. 2006;4:264-272.
STUDY
Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.
Zimmerman S, Love K, Sloane PD, Cohen LW, Reed D, Carder PC; Center for Excellence in Assisted Living-University of North Carolina Collaborative. J Am Geriatr Soc. 2011;59:1060-1068.
STUDY
A comparison of voluntarily reported medication errors in intensive care and general care units.
Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.
STUDY
Medication discrepancies upon hospital to skilled nursing facility transitions.
Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.
STUDY
Nursing home error and level of staff credentials.
Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.
STUDY
Pediatric antidepressant medication errors in a national error reporting database.
Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR. J Dev Behav Pediatr. 2010;31:129-136.
STUDY
Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.
Lapane KL, Hughes CM, Daiello LA, Cameron KA, Feinberg J. J Am Geriatr Soc. 2011;59:1238-1245.
STUDY
Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.
Gurwitz JH, Field TS, Rochon P, et al. J Am Geriatr Soc. 2008;56:2225-2233.
STUDY
Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults.
Hayes BD, Klein-Schwartz W. Clin Toxicol (Phila). 2010;48:68-71.
STUDY
Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.
Spiller HA, Borys DJ, Ryan ML, Sawyer TS, Wilson BL. Ann Pharmacother. 2011;45:17-22.
STUDY
Adverse drug events in the outpatient setting: an 11-year national analysis.
Bourgeois FT, Shannon MW, Valim C, Mandl KD. Pharmacoepidemiol Drug Saf. 2010;19:901-910.
STUDY
Medical errors in orthopaedics. Results of an AAOS member survey.
Wong DA, Herndon JH, Canale ST, et al. J Bone Joint Surg Am. 2009;91:547-557.
NEWSPAPER/MAGAZINE ARTICLE
Action needed to prevent dangerous heparin-insulin confusion.
ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.
STUDY
Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.
Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.
STUDY
Listen carefully: the risk of error in spoken medication orders.
Lambert BL, Dickey LW, Fisher WM, et al. Soc Sci Med. 2010;70:1599-1608.
REVIEW
Year in review: medication mishaps in the elderly.
Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.
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