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 (53)

•Transcription Errors (10)

•Dispensing Errors (15)

•Administration Errors (66)

•Monitoring Errors and Failures (3)

Origin/Sponsor

•Africa (2)

•Asia (12)

•Australia and New Zealand (20)

•Central and South America (1)

Resource Types

•Clinical Guideline (2)

•Journal Article (510)

•Legislation/Regulation (6)

•Meeting/Conference (4)

•Newspaper/Magazine Article (87)

•Press Release/Announcement (11)

•Special or Theme Issue (7)

•Tools/Toolkit (10)

•Web Resource (12)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (251)

•Active Errors (179)

•Latent Errors (68)

•Near Miss (18)

Approach to Improving Safety

•Quality Improvement Strategies (171)

•Legal and Policy Approaches (39)

•Error Reporting and Analysis (210)

•Communication Improvement (208)

•Human Factors Engineering (110)

•Teamwork (25)

•Specialization of Care (65)

•Logistical Approaches (32)

•Culture of Safety (68)

•Technologic Approaches (226)

•Education and Training (99)

Clinical Areas

•Allied Health Services (3)

•Medicine (471)

•Nursing (44)

•Pharmacy (215)

Target Audience

•Health Care Providers (575)

•Health Care Executives and Administrators (555)

•Non-Health Care Professionals (226)

•Patients (47)

Setting of Care

•Hospitals (418)

•Psychiatric Facilities (5)

•Residential Facilities (29)

•Ambulatory Care (109)

•Outpatient Surgery (5)

•Patient Transport (5)

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TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

REVIEW

Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review.

Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. CMAJ. 2005;173:510-515.

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.

STUDY

Applying a multidisciplinary approach to the selection, evaluation, and acquisition of smart infusion pumps.

Namshirin P, Ibey A, Lamsdale A. J Med Bio Eng. 2011;31:93-98.

STUDY

The nature and causes of unintended events reported at ten emergency departments.

Smits M, Groenewegen PP, Timmermans DRM, van der Wal G, Wagner C. BMC Emerg Med. 2009;9:16.

STUDY

Communication errors in dispatch of air medical transport.

Vilensky D, Macdonald RD. Prehosp Emerg Care. 2011;15:39-43.

STUDY

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.

REVIEW

The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials.

McKibbon KA, Lokker C, Handler SM, et al. J Am Med Inform Assoc. 2012;19:22-30.

FACT SHEET/FAQS classic

Preventing Medication Errors: A $21 Billion Opportunity.

Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.

COMMENTARY

On the Other Hand

Henneman EA. AHRQ WebM&M [serial online]. May 2007.

COMMENTARY

Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis.

Freundlich RE, Grondin L, Tremper KK, Saran KA, Kheterpal S. BMJ Qual Saf. 2012;21:850-854.

STUDY

Pharmacists' medication reconciliation-related clinical interventions in a children's hospital.

Gardner B, Graner K. Jt Comm J Qual Patient Saf. 2009;35:278-283.

NEWSPAPER/MAGAZINE ARTICLE

How we cut drug errors.

Nicol N, Huminski L. Mod Healthc. August 28, 2006;36:38.

STUDY

Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds.

Fertleman M, Barnett N, Patel T. Qual Saf Health Care. 2005;14:207-211.

AWARD RECIPIENT

Hospitals win safety award for simple changes.

Sipkoff M. Drug Topics (Health-System Edition). January 22, 2007.

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.

AUDIOVISUAL

Hospital Medication Errors Commonplace.

Palca J. National Public Radio. July 28, 2006.

COMMENTARY

Inappropriate Antibiotic Use.

Babcock HM, Fraser VJ. AHRQ WebM&M [serial online]. June 2003.

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.

COMMENTARY

Medication reconciliation in the hospital: what, why, where, when, who and how?

Fernandes O, Shojania KG. Healthc Q. 2012;15:42-49.

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