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 (173)

•Transcription Errors (21)

•Dispensing Errors (53)

•Administration Errors (214)

•Monitoring Errors and Failures (9)

Origin/Sponsor

•Africa (2)

•Asia (21)

•Australia and New Zealand (34)

•Central and South America (4)

Resource Types

•Clinical Guideline (2)

•Journal Article (949)

•Legislation/Regulation (14)

•Meeting/Conference (3)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (159)

•Press Release/Announcement (15)

•Special or Theme Issue (13)

•Tools/Toolkit (17)

•Web Resource (12)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (460)

•Active Errors (364)

•Latent Errors (91)

•Near Miss (31)

Approach to Improving Safety

•Quality Improvement Strategies (290)

•Legal and Policy Approaches (76)

•Error Reporting and Analysis (366)

•Communication Improvement (251)

•Human Factors Engineering (221)

•Teamwork (28)

•Specialization of Care (98)

•Logistical Approaches (81)

•Culture of Safety (76)

•Technologic Approaches (422)

•Education and Training (165)

Clinical Areas

•Allied Health Services (1)

Target Audience

•Health Care Providers (954)

•Health Care Executives and Administrators (952)

•Non-Health Care Professionals (399)

•Patients (84)

Setting of Care

•Hospitals (738)

•Psychiatric Facilities (6)

•Residential Facilities (38)

•Ambulatory Care (186)

•Outpatient Surgery (6)

•Patient Transport (8)

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STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

NEWSPAPER/MAGAZINE ARTICLE

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

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.

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

Determinants of patient-reported medication errors: a comparison among seven countries.

Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-740.

STUDY

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

Holden RJ, Scanlon MC, Patel NR, et al. BMJ Qual Saf. 2011;20:15-24.

COMMENTARY

Tubing safety in the obstetric setting: preventing medication errors.

Broussard BS. Nurs Womens Health. 2009;13:155-158.

STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

STUDY

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

STUDY

Hospital admission medication reconciliation in medically complex children: an observational study.

Stone BL, Boehme S, Mundorff MB, Maloney CG, Srivastava R. Arch Dis Child. 2010;95:250-255.

COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

DTaP–Tdap mix-ups now affecting hundreds of patients.

ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

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.

NEWSPAPER/MAGAZINE ARTICLE

Neuromuscular blocking agents: reducing associated wrong-drug errors.

PA-PSRS Patient Saf Advis. December 2009;6:109-114.

STUDY

The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.

Darker IT, Gerret D, Filik R, Purdy KJ, Gale AG. Ergonomics. 2011;54:21-33.

STUDY

An in-depth analysis of medication errors in hospitalized patients with HIV.

Snyder AM, Klinker K, Orrick JJ, Janelle J, Winterstein AG. Ann Pharmacother. 2011;45:459-468.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355.

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