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 (19)

•Dispensing Errors (28)

•Administration Errors (119)

•Monitoring Errors and Failures (9)

Origin/Sponsor

•Africa (2)

•Asia (22)

•Australia and New Zealand (30)

•Central and South America (3)

Resource Types

•Clinical Guideline (2)

•Journal Article (803)

•Legislation/Regulation (6)

•Meeting/Conference (3)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (93)

•Press Release/Announcement (13)

•Special or Theme Issue (7)

•Tools/Toolkit (11)

•Web Resource (12)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (499)

•Active Errors (240)

•Latent Errors (74)

•Near Miss (21)

Approach to Improving Safety

•Quality Improvement Strategies (202)

•Legal and Policy Approaches (46)

•Error Reporting and Analysis (293)

•Communication Improvement (212)

•Human Factors Engineering (130)

•Teamwork (25)

•Specialization of Care (85)

•Logistical Approaches (52)

•Culture of Safety (52)

•Technologic Approaches (423)

•Education and Training (117)

Clinical Areas

•Allied Health Services (2)

•Medicine (664)

•Nursing (80)

•Pharmacy (346)

Target Audience

•Health Care Providers (773)

•Health Care Executives and Administrators (758)

•Non-Health Care Professionals (378)

•Patients (48)

Setting of Care

•Hospitals (586)

•Psychiatric Facilities (6)

•Residential Facilities (41)

•Ambulatory Care (155)

•Outpatient Surgery (5)

•Patient Transport (8)

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COMMENTARY

In Conversation with…Eric G. Poon, MD, MPH

AHRQ WebM&M [serial online]. September 2008.

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

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-1895.

AUDIOVISUAL

Health agency: drug errors still common.

Knox R. "All Things Considered." National Public Radio. July 20, 2006.

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

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

A systematic review to evaluate the accuracy of electronic adverse drug event detection.

Forster AJ, Jennings A, Chow C, Leeder C, van Walraven C. J Am Med Inform Assoc. 2012;19:31-38.

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

Critical drug–drug interactions for use in electronic health records systems with computerized physician order entry: review of leading approaches.

Classen DC, Phansalkar S, Bates DW. J Patient Saf. 2011;7:61-65.

STUDY

Mixed results in the safety performance of computerized physician order entry.

Metzger J, Welebob E, Bates DW, Lipsitz S, Classen DC. Health Aff (Millwood). 2010;29:655-663.

STUDY

Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review.

Hunt DL, Haynes RB, Hanna SE, Smith K. JAMA. 1998;280:1339-1346.

STUDY

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.

Schnipper JL, Hamann C, Ndumele CD, et al. Arch Intern Med. 2009;169:771-780.

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

Computerized physician order entry, a factor in medication errors: descriptive analysis of events in the intensive care unit safety reporting system.

Thompson DA, Duling L, Holzmueller CG, et al. J Clin Outcomes Manage. 2005;12:407-412.

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.

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

Intravenous infusion safety technology: return on investment.

Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.

COMMENTARY

Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems.

Kilbridge PM, Welebob EM, Classen DC. Qual Saf Health Care. 2006;15:81-84.

STUDY

Prevention of potential errors in resuscitation medications orders by means of a computerised physician order entry in paediatric critical care.

Vardi A, Efrati O, Levin I, et al. Resuscitation. 2007;73:400-406.

COMMENTARY

A Mid-Summer Fog

Braddock CH. AHRQ WebM&M [serial online]. November 2008.

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