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 (202)

•Transcription Errors (27)

•Dispensing Errors (64)

•Administration Errors (117)

•Monitoring Errors and Failures (7)

Origin/Sponsor

•Asia (10)

•Australia and New Zealand (15)

Resource Types

•Clinical Guideline (2)

•Journal Article (825)

•Legislation/Regulation (11)

•Meeting/Conference (4)

•Newspaper/Magazine Article (147)

•Press Release/Announcement (14)

•Special or Theme Issue (8)

•Tools/Toolkit (21)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (369)

•Active Errors (234)

•Latent Errors (65)

•Near Miss (24)

Approach to Improving Safety

•Quality Improvement Strategies (241)

•Legal and Policy Approaches (59)

•Error Reporting and Analysis (288)

•Communication Improvement (215)

•Human Factors Engineering (155)

•Teamwork (16)

•Specialization of Care (94)

•Logistical Approaches (63)

•Culture of Safety (54)

•Technologic Approaches (465)

•Education and Training (127)

Clinical Areas

•Allied Health Services (1)

•Medicine (608)

•Nursing (102)

•Pharmacy (496)

Target Audience

•Health Care Providers (838)

•Health Care Executives and Administrators (718)

•Non-Health Care Professionals (373)

•Patients (70)

Setting of Care

•Hospitals (570)

•Psychiatric Facilities (3)

•Residential Facilities (36)

•Ambulatory Care (182)

•Outpatient Surgery (2)

•Patient Transport (3)

1 - 20 of 1079

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STUDY

The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation.

Smith DH, Perrin N, Feldstein A, et al. Arch Intern Med. 2006;166:1098-1104.

COMMENTARY

Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.

Crane J, Crane FG. Hosp Top. Fall 2006;84:3-8.

REVIEW

E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care.

Odukoya OK, Chui MA. Res Social Adm Pharm. 2012 Oct 10; [Epub ahead of print].

ORGANIZATIONAL POLICY/GUIDELINES

Electronic prescribing systems in pediatrics: the rationale and functionality requirements.

American Academy of Pediatrics Council on Clinical Information Technology. Pediatrics. 2007;119:1229-1231.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

COMMENTARY

Medication bar coding: to scan or not to scan?

Galvin L, McBeth S, Hasdorff C, Tillson M, Thomas S. Comput Inform Nurs. 2007;25:86-92.

STUDY

Medication prescribing errors involving the route of administration.

Lesar TS. Hosp Pharm. 2006;41:1053-1066.

COMMENTARY

Ordering of continuous renal replacement therapy in a computerized provider order entry system.

Oh SS, Sinclair-Pingel J, Feldott CC, Hargrove FR. Hosp Pharm. 2007;42:255–257.

STUDY

High rates of adverse drug events in a highly computerized hospital.

Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle JF. Arch Intern Med. 2005;165:1111-1116.

COMMENTARY

What medications does your patient take? Enhancing medication safety in the outpatient setting.

Institute for Healthcare Improvement. March 14, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

STUDY

Spike in fatal medication errors at the beginning of each month.

Phillips DP, Jarvinen JR, Phillips RR. Pharmacotherapy. 2005;25:1-9.

NEWSPAPER/MAGAZINE ARTICLE

To protect against drug errors, ask questions.

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

BOOK/REPORT

The Prescription Infrastructre: Are We Ready for ePrescribing?

Sarasohn-Kahn J, Holt M. Oakland, CA: California Healthcare Foundation; 2006. ISBN: 1933795026.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:556-557.

STUDY

Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies.

Grossman JM, Cross DA, Boukus ER, Cohen GR. J Am Med Inform Assoc. 2012;19:353-359.

COMMENTARY

Computerized physician order entry and medication errors: finding a balance.

Bates DW. J Biomed Inform. 2005;38:259-261.

STUDY

Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research.

Brown M, Frost R, Ko Y, Woosley R. Patient Educ Couns. 2006;62:302-315.

STUDY

Errors associated with medications removed from automated dispensing machines using override functions.

Kester K, Baxter J, Freudenthal K. Hosp Pharm. 2006;41:535-537.

MEASUREMENT TOOL/INDICATOR

National Survey of Safety Features with Pharmacy Computer Systems.

Huntingdon Valley, PA: Institute for Safe Medication Practices; 2005.

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