AHRQ Patient Safety Network

The Collection > Medication Errors/Preventable Adverse Drug Events

PATIENT SAFETY PRIMERS
Medication Errors

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Medication Errors/Preventable Adverse Drug Events

•Ordering/Prescribing Errors (96)

•Transcription Errors (18)

•Dispensing Errors (54)

•Administration Errors (107)

•Monitoring Errors and Failures (5)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (11)

Resource Types

•Clinical Guideline (2)

•Journal Article (672)

•Legislation/Regulation (8)

•Meeting/Conference (3)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (163)

•Press Release/Announcement (14)

•Special or Theme Issue (7)

•Tools/Toolkit (22)

•Web Resource (14)

Error Types

•Epidemiology of Errors and Adverse Events (329)

•Active Errors (288)

•Latent Errors (69)

•Near Miss (24)

Approach to Improving Safety

•Quality Improvement Strategies (238)

•Legal and Policy Approaches (68)

•Error Reporting and Analysis (274)

•Communication Improvement (200)

•Human Factors Engineering (156)

•Teamwork (19)

•Specialization of Care (80)

•Logistical Approaches (61)

•Culture of Safety (52)

•Technologic Approaches (319)

•Education and Training (133)

Clinical Areas

•Allied Health Services (1)

Target Audience

•Health Care Providers (722)

•Health Care Executives and Administrators (631)

•Non-Health Care Professionals (267)

•Patients (111)

Setting of Care

•Hospitals (506)

•Psychiatric Facilities (3)

•Residential Facilities (35)

•Ambulatory Care (170)

•Outpatient Surgery (4)

•Patient Transport (5)

1 - 20 of 947

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NEWSPAPER/MAGAZINE ARTICLE

Pill errors cost pharmacists cash, not career.

Dworkin A. The Oregonian. June 20, 2007:A01.

NEWSPAPER/MAGAZINE ARTICLE

Parents sue over babies' heparin overdoses: infants were given too much heparin at Methodist Hospital.

Higgins W. Indianapolis Star. September 13, 2008;News section:A1

AUDIOVISUAL

State launches 3rd priority investigation into Children's.

Vedder T. Problem Solvers. KOMO 4 News. October 1, 2010.

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.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Drug errors are dangerous but preventable.

Washington Post; August 31, 2010:HE02.

NEWSPAPER/MAGAZINE ARTICLE

The harm in pharmacy misfills.

Young A. The Atlanta Journal-Constitution; September 20, 2009:B1.

NEWSPAPER/MAGAZINE ARTICLE

Medication mistakes that can kill.

Haiken M. Caring.com. August 17, 2009.

NEWSPAPER/MAGAZINE ARTICLE

Pharmacy reform reduces Rx errors: '05 CVS mishap spurred action.

Fargen J. Boston Herald. April 22, 2007.

AUDIOVISUAL

Pharmacy mixes up prescriptions.

Haythorn R. ABC News. February 7, 2011.

COMMENTARY

Improving care transitions: current practice and future opportunities for pharmacists.

American College of Clinical Pharmacy, Hume AL, Kirwin J, et al. Pharmacotherapy. 2012;32:e326-e337.

FACT SHEET/FAQS classic

Preventing Medication Errors: A $21 Billion Opportunity.

Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.

STUDY

ED overcrowding is associated with an increased frequency of medication errors.

Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. Am J Emerg Med. 2010;28:304-309.

BOOK/REPORT

To Err Is Human — To Delay Is Deadly.

Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009.

NEWSPAPER/MAGAZINE ARTICLE

Fatal error sparks debate over punitive measures.

Fernandez J. Drug Topics. May 7, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg.

ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.

FACT SHEET/FAQS

An 8-Step Check List for Medicine Safety.

Vienna, VA: The Partnership for Safe Medicines; 2005.

COMMENTARY

'Inattentional blindness': what captures your attention?

Grissinger M. P T. 2012;37:542-555.

COMMENTARY

Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge.

Rodehaver C. Jt Comm J Qual Patient Saf. 2005;31:406-413.

NEWSPAPER/MAGAZINE ARTICLE

To protect against drug errors, ask questions.

Brody JE. New York Times. January 2, 2007:F7.

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