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 (101)

•Transcription Errors (24)

•Dispensing Errors (39)

•Administration Errors (126)

•Monitoring Errors and Failures (6)

Origin/Sponsor

•Africa (1)

•Asia (13)

•Australia and New Zealand (19)

Resource Types

•Clinical Guideline (2)

•Journal Article (748)

•Legislation/Regulation (10)

•Meeting/Conference (3)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (157)

•Press Release/Announcement (8)

•Special or Theme Issue (12)

•Tools/Toolkit (20)

•Web Resource (9)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (345)

•Active Errors (226)

•Latent Errors (83)

•Near Miss (26)

Approach to Improving Safety

•Quality Improvement Strategies (248)

•Legal and Policy Approaches (66)

•Error Reporting and Analysis (299)

•Communication Improvement (262)

•Human Factors Engineering (162)

•Teamwork (21)

•Specialization of Care (89)

•Logistical Approaches (73)

•Culture of Safety (73)

•Technologic Approaches (346)

•Education and Training (151)

Clinical Areas

•Allied Health Services (3)

•Medicine (599)

•Nursing (133)

•Pharmacy (391)

Target Audience

•Health Care Providers (767)

•Health Care Executives and Administrators (734)

•Non-Health Care Professionals (300)

•Patients (81)

Setting of Care

•Hospitals (655)

•Psychiatric Facilities (4)

•Residential Facilities (35)

•Ambulatory Care (147)

•Outpatient Surgery (5)

•Patient Transport (9)

1 - 20 of 1023

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NEWSPAPER/MAGAZINE ARTICLE

Survey results: community liaison programs to decrease hospital readmissions.

ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Enhanced medication safety.

Mansur JM. Hosp Health Netw. April 29, 2008.

STUDY

Effectiveness of a pharmacist–nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care.

Setter SM, Corbett CF, Neumiller JJ, Gates BJ, Sclar DA, Sonnett TE. Am J Health Syst Pharm. 2009;66:2027-2031.

NEWSPAPER/MAGAZINE ARTICLE

Health for life. Keys to safer hospitals.

Berwick DM. Newsweek. December 12, 2005;46:75-78.

BOOK/REPORT

Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.

Rockville, MD: United States Pharmacopeia; 2007.

STUDY

Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center.

Strunk LB, Matson AW, Steinke D. Hosp Pharm. 2008;43:643-649.

NEWSPAPER/MAGAZINE ARTICLE

JCAHO views medication reconciliation as adverse-event prevention.

Thompson CA. Am J Health Syst Pharm. 2005;62:1528-1532.

COMMENTARY

Improving care transitions: current practice and future opportunities for pharmacists.

American College of Clinical Pharmacy, Hume AL, Kirwin J, et al. Pharmacotherapy. 2012;32:e326-e337.

COMMENTARY

On the Other Hand

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

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

STUDY

Medication discrepancies upon hospital to skilled nursing facility transitions.

Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

NEWSPAPER/MAGAZINE ARTICLE

Medication reconciliation only as good as the IT allows.

Page D. Hosp Health Networks. March 2011.

NEWSPAPER/MAGAZINE ARTICLE

Using clinical decision support to improve medication reconciliation.

Moore G. Patient Saf Qual Healthc. November/December 2006;3:28-30, 32-33.

NEWSPAPER/MAGAZINE ARTICLE

Patients taking their own medications while in the hospital.

PA-PSRS Patient Saf Advis. June 2012;9:50-57.

STUDY

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

Poon EG, Blumenfeld B, Hamann C, et al. J Am Med Inform Assoc. 2006;13:581-592.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

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

NEWSPAPER/MAGAZINE ARTICLE

Lack of standard dosing methods contributes to IV errors.

ISMP Medication Safety Alert! Acute Care Edition. August 23, 2007;12:1-3.

STUDY

Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases.

Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-847.

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.

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