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PATIENT SAFETY PRIMERS
Medication Errors
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COMMENTARY
ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.
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.
STUDY
Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.
Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.
STUDYclassic
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.
STUDY
What’s past is prologue: organizational learning from a serious patient injury.
Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.
NEWSPAPER/MAGAZINE ARTICLE
Medication errors occurring with the use of bar-code administration technology.
PA-PSRS Patient Saf Advis. December 2008;5:122-126.
STUDY
Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.
Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.
STUDY
Medication errors recovered by emergency department pharmacists.
Rothschild JM, Churchill W, Erickson A, et al. Ann Emerg Med. 2010;55:513-521.
NEWSPAPER/MAGAZINE ARTICLE
Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.
ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.
STUDY
Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.
Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.
REVIEW
Bar code technology and medication administration error.
Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.
REVIEW
Systematic review of medication safety assessment methods.
Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Am J Health Syst Pharm. 2011;68:227-240.
NEWSPAPER/MAGAZINE ARTICLE
The 'second victims' of medication errors begin to gain support.
Blum K. Pharm Pract News. November 2011.
NEWSPAPER/MAGAZINE ARTICLE
Medication errors: a year in review.
Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.
STUDY
Full implementation of computerized physician order entry and medication-related quality outcomes: a study of 3364 hospitals.
Yu FB, Menachemi N, Berner ES, Allison JJ, Weissman NW, Houston TK. Am J Med Qual. 2009;24:278-286.
ORGANIZATIONAL POLICY/GUIDELINES
Preventing errors relating to commonly used anticoagulants.
Sentinel Event Alert. September 24, 2008;(41):1-4.
STUDY
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011.
Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2012;69:768-785.
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
The costs of adverse drug events in community hospitals.
Hug BL, Keohane C, Seger DL, Yoon C, Bates DW. Jt Comm J Qual Patient Saf. 2012;38:120-126.
BOOK/REPORT
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.
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