AHRQ Patient Safety Network

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Dispensing Errors

Origin/Sponsor

•Australia and New Zealand (1)

Resource Types

•Journal Article (65)

•Newspaper/Magazine Article (20)

•Press Release/Announcement (3)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (22)

•Active Errors (34)

•Latent Errors (15)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (19)

•Legal and Policy Approaches (9)

•Error Reporting and Analysis (26)

•Communication Improvement (15)

•Human Factors Engineering (26)

•Teamwork (2)

•Specialization of Care (5)

•Logistical Approaches (11)

•Culture of Safety (5)

•Technologic Approaches (45)

•Education and Training (11)

Clinical Areas

•Medicine (41)

•Nursing (8)

•Pharmacy (77)

Target Audience

•Health Care Providers (80)

•Health Care Executives and Administrators (58)

•Non-Health Care Professionals (32)

•Patients (10)

Setting of Care

•Hospitals (45)

•Residential Facilities (1)

•Ambulatory Care (28)

•Outpatient Surgery (1)

1 - 20 of 94

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NEWSPAPER/MAGAZINE ARTICLE

Follow ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs).

ISMP Medication Safety Alert! Acute Care Edition. February 12, 2009;14:1-4.

STUDY

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

Horsham, PA: Institute for Safe Medication Practices; 2009.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:730-733.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:844-847.

STUDY

Automated drug dispensing system reduces medication errors in an intensive care setting.

Chapuis C, Roustit M, Bal G, et al. Crit Care Med. 2010;38:2275-2281.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:1148-1151.

NEWSPAPER/MAGAZINE ARTICLE

Events associated with the prescribing, dispensing, and administering of medication loading doses.

Carson SL, Gaunt MJ. PA-PSRS Patient Saf Advis. 2012;9:82-88.

COMMENTARY

Vial Mistakes Involving Heparin.

Vanderveen T. AHRQ WebM&M [serial online]. May 2009.

NEWSPAPER/MAGAZINE ARTICLE

Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Dose of technology helps Shands at UF avoid drug errors.

Chun D. Gainsville Sun. August 21, 2006.

STUDY

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.

COMMENTARY

Automated dispensing cabinets.

Gaunt MJ, Johnston J, Davis MM. Am J Nurs. 2007;107:27-28.

NEWSPAPER/MAGAZINE ARTICLE

Safety still compromised by computer weaknesses.

ISMP Medication Safety Alert! Acute Care Edition. August 25, 2005;10:1-3.

NEWSPAPER/MAGAZINE ARTICLE

ADC survey shows some improvements, but unnecessary risks still exist.

ISMP Medication Safety Alert! Acute Care Edition. January 17, 2008;13:1-2.

STUDY

Dispensing errors and counseling quality in 100 pharmacies.

Flynn EA, Barker KN, Berger BA, Lloyd KB, Brackett PD. J Am Pharm Assoc. 2009;49:171-180.

NEWSPAPER/MAGAZINE ARTICLE

Two steps forward and one step back for patient safety?

ISMP Medication Safety Alert! Acute Care Edition. June 30, 2005;10.

STUDY

Pharmacist workload and pharmacy characteristics associated with the dispensing of potentially clinically important drug-drug interactions.

Malone DC, Abarca J, Skrepnek GH, et al. Med Care. 2007;45:456-462.

NEWSPAPER/MAGAZINE ARTICLE

Good intention, uncertain outcome...our take on physician dispensing in offices and clinics.

ISMP Medication Safety Alert! Acute Care Edition. March 8, 2012;17:1-3.

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