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 (239)

•Transcription Errors (29)

•Dispensing Errors (62)

•Administration Errors (234)

•Monitoring Errors and Failures (9)

Origin/Sponsor

•Africa (2)

•Asia (25)

•Australia and New Zealand (38)

•Central and South America (5)

•Europe (189)

•North America (1070)

Resource Types

•Audiovisual (18)

•Award (3)

•Book/Report (31)

•Clinical Guideline (2)

•Journal Article (1077)

•Legislation/Regulation (14)

•Meeting/Conference (4)

•Newspaper/Magazine Article (165)

•Press Release/Announcement (13)

•Special or Theme Issue (14)

•Tools/Toolkit (17)

•Web Resource (12)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (564)

•Active Errors (375)

•Latent Errors (100)

•Near Miss (30)

Approach to Improving Safety

•Quality Improvement Strategies (295)

•Legal and Policy Approaches (78)

•Error Reporting and Analysis (392)

•Communication Improvement (273)

•Human Factors Engineering (234)

•Teamwork (29)

•Specialization of Care (107)

•Logistical Approaches (87)

•Culture of Safety (73)

•Technologic Approaches (509)

•Education and Training (186)

Clinical Areas

•Allied Health Services (2)

•Medicine (838)

•Nursing (164)

•Pharmacy (503)

Target Audience

•Health Care Providers (1036)

•Health Care Executives and Administrators (1011)

•Non-Health Care Professionals (465)

•Patients (84)

Setting of Care

•Hospitals (805)

•Psychiatric Facilities (7)

•Residential Facilities (44)

•Ambulatory Care (222)

•Outpatient Surgery (6)

•Patient Transport (9)

1 - 20 of 1371

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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.

STUDY

An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies.

Palchuk MB, Fang EA, Cygielnik JM, et al. J Am Med Inform Assoc. 2010;17:472-476.

STUDY

Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.

Hug BL, Witkowski DJ, Sox CM, et al. J Gen Intern Med. 2010;25:31-38.

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

Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.

Terrell KM, Perkins AJ, Hui SL, Callahan CM, Dexter PR, Miller DK. Ann Emerg Med. 2010;56:623-629.

COMMENTARY

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

Carspecken CW, Sharek PJ, Longhurst C, Pageler NM. Pediatrics. 2013;131:e1970-e1973.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

STUDY

Impact of health information technology on detection of potential adverse drug events at the ordering stage.

Roberts LL, Ward MM, Brokel JM, Wakefield DS, Crandall DK, Conlon P. Am J Health Syst Pharm. 2010;67:1838-1846.

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

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

Pham JC, Story JL, Hicks RW, et al. J Emerg Med. 2011;40:485-492.

STUDY

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.

STUDY

Time-dependent drug–drug interaction alerts in care provider order entry: software may inhibit medication error reductions.

van der Sijs H, Lammers L, van den Tweel A, et al. J Am Med Inform Assoc. 2009;16:864-868.

STUDY

Outpatient adverse drug events identified by screening electronic health records.

Gandhi TK, Seger AC, Overhage JM, et al. J Patient Saf. 2010;6;91-96.

STUDY

The relationship between computerized physician order entry and pediatric adverse drug events: a nested matched case-control study.

Yu F, Salas M, Kim YI, Menachemi N. Pharmacoepidemiol Drug Saf. 2009;18:751-755.

STUDY

Effect of bar-code technology on the safety of medication administration.

Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.

STUDY

Comparison of methods for identifying patients at risk of medication-related harm.

van Doormaal JE, Rommers MK, Kosterink JGW, Teepe-Twiss IM, Haaijer-Ruskamp FM, Mol PGM. Qual Saf Health Care. 2010;19:e26.

STUDY

Electronic prescribing improves medication safety in community-based office practices.

Kaushal R, Kern LM, Barrón Y, Quaresimo J, Abramson EL. J Gen Intern Med. 2010;25:530-536.

STUDY

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ. BMC Med Inform Decis Mak. 2011;11:29.

STUDY

A framework for evaluating the appropriateness of clinical decision support alerts and responses.

McCoy AB, Waitman LR, Lewis JB, et al. J Am Med Inform Assoc. 2012;19:346-352.

STUDY

Predictive value of alert triggers for identification of developing adverse drug events.

Moore C, Li J, Hung CC, Downs J, Nebeker JR. J Patient Saf. 2009;5:223-228.

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