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 (33)

•Transcription Errors (5)

•Dispensing Errors (10)

•Administration Errors (37)

Origin/Sponsor

•Africa (2)

•Asia (16)

•Australia and New Zealand (22)

•Central and South America (3)

Resource Types

•Clinical Guideline (1)

•Journal Article (513)

•Legislation/Regulation (3)

•Newspaper/Magazine Article (62)

•Press Release/Announcement (3)

•Special or Theme Issue (1)

•Tools/Toolkit (2)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (412)

•Active Errors (116)

•Latent Errors (39)

•Near Miss (16)

Approach to Improving Safety

•Quality Improvement Strategies (110)

•Legal and Policy Approaches (23)

•Error Reporting and Analysis (227)

•Communication Improvement (132)

•Human Factors Engineering (67)

•Teamwork (14)

•Specialization of Care (58)

•Logistical Approaches (39)

•Culture of Safety (36)

•Technologic Approaches (194)

•Education and Training (67)

Clinical Areas

•Allied Health Services (2)

•Medicine (390)

•Nursing (68)

•Pharmacy (233)

Target Audience

•Health Care Providers (438)

•Health Care Executives and Administrators (461)

•Non-Health Care Professionals (174)

•Patients (23)

Setting of Care

•Hospitals (471)

•Psychiatric Facilities (3)

•Residential Facilities (27)

•Ambulatory Care (91)

•Outpatient Surgery (3)

•Patient Transport (5)

1 - 20 of 613

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NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

PA-PSRS Patient Saf Advis. March 2012;9:11-17.

STUDY

Medication errors involving patient-controlled analgesia.

Hicks RW, Sikirica V, Nelson W, Schein JR, Cousins DD. Am J Health Syst Pharm. 2008;65:429-440.

STUDY

Prescribing discrepancies likely to cause adverse drug events after patient transfer.

Boockvar KS, Liu S, Goldstein N, Nebeker J, Siu A, Fried T. Qual Saf Health Care. 2009;18:32-36.

STUDY

Nursing perception of the impact of medication carts on patient safety and ergonomics in a teaching health care center.

Rochais É, Atkinson S, Bussières JF. J Pharm Pract. 2013;26:131-137.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

COMMENTARY

Eliminating adverse drug events at Ascension Health.

Butler K, Mollo P, Gale JL, Rapp DA. Jt Comm J Qual Patient Saf. 2007;33:527-536.

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

The Research on Adverse Drug Events and Reports (RADAR) project.

Bennett CL, Nebeker JR, Lyons EA, et al. JAMA. 2005;293:2131-2140.

STUDY

Retrospective analysis of medication incidents reported using an on-line reporting system.

Ashcroft DM, Cooke J. Pharm World Sci. 2006;28:359-65.

REVIEW

Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems.

Radley DC, Wasserman MR, Olsho LE, Shoemaker SJ, Spranca MD, Bradshaw B. J Am Med Inform Assoc. 2013;20:470-476.

COMMENTARY

Improving care transitions: optimizing medication reconciliation.

American Pharmacists Association, American Society of Health-System Pharmacists. J Am Pharm Assoc. 2012;52:e43-e52.

NEWSPAPER/MAGAZINE ARTICLE

Fluorouracil error ends tragically, but application of lessons learned will save lives.

ISMP Medication Safety Alert! Acute Care Edition. September 20, 2007;12:1-3.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:547-550, 554.

BOOK/REPORT

Adverse Drug Events in US Hospitals, 2004.

Elixhauser A, Owens P. HCUP Statistical Brief #29. Rockville, MD: Agency for Healthcare Research and Quality; April 2007.

STUDY

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

Waitman LR, Phillips IE, McCoy AB, et al. Jt Comm J Qual Patient Saf. 2011;37:326-332.

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.

REVIEW

Hospital-based medication reconciliation practices: a systematic review.

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

STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

STUDY

Impact of vendor computerized physician order entry in community hospitals.

Leung AA, Keohane C, Amato M, et al. J Gen Intern Med. 2012;27:801-807.

STUDY

Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hospitalist and specialist care.

Anderegg SV, Demik DE, Carter BL, et al. Pharmacotherapy. 2013;33:11-21.

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