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 (134)

•Transcription Errors (29)

•Dispensing Errors (39)

•Administration Errors (163)

•Monitoring Errors and Failures (9)

Origin/Sponsor

•Africa (1)

•Asia (12)

•Australia and New Zealand (19)

Resource Types

•Clinical Guideline (3)

•Journal Article (765)

•Legislation/Regulation (15)

•Meeting/Conference (3)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (167)

•Press Release/Announcement (16)

•Special or Theme Issue (12)

•Tools/Toolkit (23)

•Web Resource (15)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (319)

•Active Errors (223)

•Latent Errors (71)

•Near Miss (26)

Approach to Improving Safety

•Quality Improvement Strategies (287)

•Legal and Policy Approaches (73)

•Error Reporting and Analysis (311)

•Communication Improvement (250)

•Human Factors Engineering (154)

•Teamwork (20)

•Specialization of Care (86)

•Logistical Approaches (70)

•Culture of Safety (73)

•Technologic Approaches (361)

•Education and Training (157)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (848)

•Health Care Executives and Administrators (737)

•Non-Health Care Professionals (298)

•Patients (113)

Setting of Care

•Hospitals (580)

•Psychiatric Facilities (5)

•Residential Facilities (41)

•Ambulatory Care (163)

•Outpatient Surgery (4)

•Patient Transport (6)

1 - 20 of 1074

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COMMENTARY

System errors in intrapartum electronic fetal monitoring: a case review.

Miller LA. J Midwifery Womens Health. 2005;50:507-516.

COMMENTARY

Improving safety throughout the medication use process in a neonatal intensive care unit.

Asdigha MN. Hosp Pharm. 2006;41:1067-1075.

NEWSPAPER/MAGAZINE ARTICLE

Nurse is charged in death of patient.

Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.

COMMENTARY

Best-practice protocols: Preventing adverse drug events.

Weir VL. Nurs Manage. 2005;36:24-30.

TOOLKIT

Looking Collectively at Risk.

Pathways for Medication Safety Tool #2. Chicago, IL: American Hospital Association; 2003.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

PA-PSRS Patient Saf Advis. December 2005;2:29-31.

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

Risk factors for adverse drug events: a 10-year analysis.

Evans RS, Lloyd JF, Stoddard GJ, Nebeker JR, Samore MH. Ann Pharmacother. 2005;39:1161-1168.

STUDY

Infant deaths associated with cough and cold medications—two states, 2005.

Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2007;56:1-4.

NEWSPAPER/MAGAZINE ARTICLE

Nurse error spotlights drug's danger.

Greene L. St. Petersburg Times. June 15, 2006:A1.

FACT SHEET/FAQS

Oral Dosage Forms that Should Not Be Crushed.

Mitchell JF. Institute for Safe Medication Practices.

NEWSPAPER/MAGAZINE ARTICLE

Error rate greatest in hospital radiology.

Stein R. The Washington Post. January 18, 2006:A03.

NEWSPAPER/MAGAZINE ARTICLE

IV potassium given epidurally: getting to the "route" of the problem.

ISMP Medication Safety Alert! Acute Care Edition. April 6, 2006;11:1-2.

ORGANIZATIONAL POLICY/GUIDELINES

AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span.

AORN J. 2006;84:276-278, 280-283.

STUDY

Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.

Goodman EJ, Haas AJ, Kantor GS. Int J Obstet Anesth. 2006;15:63-67.

STUDY

The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors in a UK intensive care unit.

Sanghera IS, Franklin BD, Dhillon S. Anaesthesia. 2007;62:53-61.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:675-679.

NEWSPAPER/MAGAZINE ARTICLE

200 epidural blunders admitted after three women die.

Oakeshott I. The Sunday Times. June 18, 2006.

STUDY

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.

REVIEW

The National Quality Forum safe practice standard for computerized physician order entry: updating a critical patient safety practice.

Kilbridge PM, Classen D, Bates DW, Denham CR. J Patient Saf. 2006;2:183-190.

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