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PATIENT SAFETY PRIMERS
Medication Errors

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Medication Errors/Preventable Adverse Drug Events

•Ordering/Prescribing Errors (117)

•Transcription Errors (23)

•Dispensing Errors (45)

•Administration Errors (125)

•Monitoring Errors and Failures (3)

Origin/Sponsor

•Australia and New Zealand (21)

•Central and South America (2)

•North America (873)

Resource Types

•Audiovisual (16)

•Book/Report (31)

•Clinical Guideline (2)

•Journal Article (755)

•Legislation/Regulation (11)

•Meeting/Conference (2)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (157)

•Press Release/Announcement (7)

•Special or Theme Issue (10)

•Tools/Toolkit (19)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (360)

•Active Errors (216)

•Latent Errors (73)

•Near Miss (26)

Approach to Improving Safety

•Quality Improvement Strategies (226)

•Legal and Policy Approaches (63)

•Error Reporting and Analysis (292)

•Communication Improvement (243)

•Human Factors Engineering (163)

•Teamwork (20)

•Specialization of Care (100)

•Logistical Approaches (75)

•Culture of Safety (70)

•Technologic Approaches (370)

•Education and Training (141)

Clinical Areas

•Allied Health Services (2)

•Dentistry (1)

•Medicine (594)

•Nursing (131)

•Pharmacy (430)

Target Audience

•Health Care Providers (769)

•Health Care Executives and Administrators (741)

•Non-Health Care Professionals (309)

•Patients (78)

Setting of Care

•Hospitals (678)

•Psychiatric Facilities (4)

•Residential Facilities (34)

•Ambulatory Care (137)

•Outpatient Surgery (5)

•Patient Transport (6)

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REVIEW

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Hospital-based medication reconciliation practices: a systematic review.

Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Arch Intern Med. 2012;172:1057-1069.

NEWSPAPER/MAGAZINE ARTICLE

Enhanced medication safety.

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

NEWSPAPER/MAGAZINE ARTICLE

Medication reconciliation only as good as the IT allows.

Page D. Hosp Health Networks. March 2011.

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.

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.

NEWSPAPER/MAGAZINE ARTICLE

JCAHO views medication reconciliation as adverse-event prevention.

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

COMMENTARY

Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge.

Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Am J Health Syst Pharm. 2009;66:2126-2131.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:884–888.

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.

STUDY

Reporting trends in a regional medication error data-sharing system.

Anderson JG, Ramanujam R, Hensel DJ, Sirio CA. Health Care Manag Sci. 2010;13:74-83.

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.

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

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

A shortage of everything except errors: harm associated with drug shortages.

ISMP Medication Safety Alert! Acute Care Edition. April 19, 2012;17:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Misprogramming PCA concentration leads to dosing errors.

ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.

REVIEW

Medication reconciliation during transitions of care as a patient safety strategy: a systematic review.

Kwan JL, Lo L, Sampson M, Shojania KG. Ann Intern Med. 2013;158(5 Pt 2):397-403.

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.

STUDY

Impact of a pharmacotherapy alerting system on medication errors.

Natali BJ, Varkey AC, Garey KW, Liebl M. Am J Health Syst Pharm. 2013;70:48-52.

STUDY

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Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.

Kripalani S, Roumie CL, Dalal AK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Ann Intern Med. 2012;157:1-10.

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