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 (194)

•Transcription Errors (21)

•Dispensing Errors (52)

•Administration Errors (217)

•Monitoring Errors and Failures (10)

Origin/Sponsor

•Africa (3)

•Asia (25)

•Australia and New Zealand (36)

•Central and South America (4)

•Europe (158)

•North America (1016)

Resource Types

•Audiovisual (15)

•Award (4)

•Book/Report (28)

•Clinical Guideline (2)

•Journal Article (984)

•Legislation/Regulation (15)

•Meeting/Conference (3)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (167)

•Press Release/Announcement (13)

•Special or Theme Issue (13)

•Tools/Toolkit (19)

•Web Resource (11)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (472)

•Active Errors (339)

•Latent Errors (94)

•Near Miss (30)

Approach to Improving Safety

•Quality Improvement Strategies (296)

•Legal and Policy Approaches (72)

•Error Reporting and Analysis (378)

•Communication Improvement (268)

•Human Factors Engineering (226)

•Teamwork (28)

•Specialization of Care (105)

•Logistical Approaches (89)

•Culture of Safety (84)

•Technologic Approaches (441)

•Education and Training (178)

Clinical Areas

•Allied Health Services (1)

•Medicine (792)

•Nursing (166)

•Pharmacy (461)

Target Audience

•Health Care Providers (978)

•Health Care Executives and Administrators (948)

•Non-Health Care Professionals (406)

•Patients (80)

Setting of Care

•Hospitals (812)

•Psychiatric Facilities (6)

•Residential Facilities (38)

•Ambulatory Care (190)

•Outpatient Surgery (6)

•Patient Transport (9)

1 - 20 of 1278

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STUDY

Medication reconciliation: a qualitative analysis of clinicians' perceptions.

Vogelsmeier A, Pepper GA, Oderda L, Weir C. Res Social Adm Pharm. 2012 Oct 19; [Epub ahead of print].

NEWSPAPER/MAGAZINE ARTICLE

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

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

BOOK/REPORT

2009 National Healthcare Quality Report.

Rockville, MD: Agency for Healthcare Research and Quality; March 2010. AHRQ Publication No. 10-0003.

STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

STUDY

Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study.

Hartnell N, MacKinnon N, Sketris I, Fleming M. BMJ Qual Saf. 2012;21:361-368.

NEWSPAPER/MAGAZINE ARTICLE

Raising the index of suspicion: red flags that represent credible threats to patient safety.

ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.

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.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.

STUDY

Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge.

Ziaeian B, Araujo KLB, Van Ness PH, Horwitz LI. J Gen Intern Med. 2012;27:1513-1520.

STUDY

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.

BOOK/REPORT

First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety.

Koppel R, Gordon S, ed. Ithaca, NY: Cornell University Press; 2012. ISBN: 9780801450778.

STUDY

Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting.

Makowsky MJ, Schindel TJ, Rosenthal M, Campbell K, Tsuyuki RT, Madill HM. J Interprof Care. 2009;23:169-84.

STUDY

Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation.

Benning A, Ghaleb M, Suokas A, et al. BMJ. 2011;342:d195.

STUDY

Full implementation of computerized physician order entry and medication-related quality outcomes: a study of 3364 hospitals.

Yu FB, Menachemi N, Berner ES, Allison JJ, Weissman NW, Houston TK. Am J Med Qual. 2009;24:278-286.

STUDY

A July spike in fatal medication errors: a possible effect of new medical residents.

Phillips DP, Barker GEC. J Gen Intern Med. 2010;25:774-779.

STUDY

An exploratory study measuring verbal order content and context.

Wakefield DS, Brokel J, Ward MM, Schwichtenberg T, Groath D, Kolb M, Davis JW, Crandall D. Qual Saf Health Care. 2009;18:169-173.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

Salanitro AH, Osborn CY, Schnipper JL, et al. J Gen Intern Med. 2012;27:924-932.

COMMENTARY

Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project.

Harding AD. Am J Nurs. 2012;112:26-35.

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