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 (87)

•Transcription Errors (18)

•Dispensing Errors (33)

•Administration Errors (35)

•Monitoring Errors and Failures (5)

Origin/Sponsor

•Africa (1)

•Asia (9)

•Australia and New Zealand (12)

Resource Types

•Clinical Guideline (1)

•Journal Article (476)

•Legislation/Regulation (5)

•Meeting/Conference (4)

•Newspaper/Magazine Article (78)

•Press Release/Announcement (9)

•Special or Theme Issue (4)

•Tools/Toolkit (15)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (246)

•Active Errors (129)

•Latent Errors (47)

•Near Miss (9)

Approach to Improving Safety

•Quality Improvement Strategies (157)

•Legal and Policy Approaches (30)

•Error Reporting and Analysis (172)

•Communication Improvement (207)

•Human Factors Engineering (82)

•Teamwork (13)

•Specialization of Care (63)

•Logistical Approaches (30)

•Culture of Safety (35)

•Technologic Approaches (199)

•Education and Training (95)

Clinical Areas

•Allied Health Services (1)

•Medicine (398)

•Nursing (42)

•Pharmacy (369)

Target Audience

•Health Care Providers (502)

•Health Care Executives and Administrators (399)

•Non-Health Care Professionals (154)

•Patients (41)

Setting of Care

•Hospitals (311)

•Psychiatric Facilities (1)

•Residential Facilities (31)

•Ambulatory Care (137)

•Outpatient Surgery (1)

•Patient Transport (2)

1 - 20 of 623

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STUDY

Frequency of risk factors that potentially increase harm from medications in older adults receiving primary care.

McCarthy L, Dolovich L, Haq M, Thabane L, Kaczorowski J. Can J Clin Pharmacol. 2007;14:e283-e290.

STUDY

The effect of medication reconciliation in elderly patients at hospital discharge.

Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. Int J Clin Pharm. 2012;34:113-119.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

STUDY

Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital.

Midlöv P, Deierborg E, Holmdahl L, Höglund P, Eriksson T. Pharm World Sci. 2008;30:840-845.

STUDY

Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research.

Brown M, Frost R, Ko Y, Woosley R. Patient Educ Couns. 2006;62:302-315.

STUDY

Improving medication reconciliation in the outpatient setting.

Varkey P, Cunningham J, Bisping S. Jt Comm J Qual Patient Saf. 2007;33:286-292.

STUDY

Multidose drug dispensing and discrepancies between medication records.

Wekre LJ, Spigset O, Sletvold O, Sund JK, Grimsmo A. Qual Saf Health Care. 2010;19:e42.

GRANT RECIPIENT

AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care.

Rockville, MD: Agency for Healthcare Research and Quality; October 2008.

STUDY

Sources and types of discrepancies between electronic medical records and actual outpatient medication use.

Orrico KB. J Manag Care Pharm. 2008;14:626-631.

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.

STUDY

Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities.

Mira JJ, Orozco-Beltrán D, Pérez-Jover V, et al. Fam Pract. 2013;30:56-63.

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.

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.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety records: silent witness.

Gould M. Health Service Journal. September 15, 2008:22-24.

STUDY

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.

Stewart AL, Lynch KJ. J Am Pharm Assoc (2003). 2012;52:59-66.

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.

STUDY

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.

STUDY

Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients.

Cornu P, Steurbaut S, Leysen T, et al. Ann Pharmacother. 2012;46:484-494.

STUDY

Bayesian cohort and cross-sectional analyses of the PINCER trial: a pharmacist-led intervention to reduce medication errors in primary care.

Hemming K, Chilton PJ, Lilford RJ, Avery A, Sheikh A. PLoS ONE. 2012;7:e38306.

STUDY

Usability of a computerised drug monitoring programme to detect adverse drug events and non-compliance in outpatient ambulatory care.

Auger C, Forster AJ, Oake N, Tamblyn R. BMJ Qual Saf. 2013;22:306-316.

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