AHRQ Patient Safety Network

The Collection > Dispensing Errors

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Dispensing Errors

Origin/Sponsor

•Australia and New Zealand (2)

•Central and South America (1)

Resource Types

•Journal Article (66)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (19)

•Press Release/Announcement (2)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (20)

•Active Errors (34)

•Latent Errors (15)

•Near Miss (3)

Approach to Improving Safety

•Quality Improvement Strategies (21)

•Legal and Policy Approaches (9)

•Error Reporting and Analysis (23)

•Communication Improvement (15)

•Human Factors Engineering (27)

•Teamwork (2)

•Specialization of Care (6)

•Logistical Approaches (10)

•Culture of Safety (4)

•Technologic Approaches (46)

•Education and Training (9)

Clinical Areas

•Medicine (42)

•Nursing (8)

•Pharmacy (74)

Target Audience

•Health Care Providers (81)

•Health Care Executives and Administrators (57)

•Non-Health Care Professionals (30)

•Patients (9)

Setting of Care

•Hospitals (48)

•Residential Facilities (1)

•Ambulatory Care (28)

•Outpatient Surgery (1)

1 - 20 of 94

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SPECIAL OR THEME ISSUE

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

STUDY

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008.

Pedersen CA, Schneider P, Scheckelhoff DJ. Am J Health Syst Pharm. 2009;66:926-946.

NEWSPAPER/MAGAZINE ARTICLE

Officials investigate infants' heparin OD at Texas hospital.

Vonfremd M, Ibanga I. ABC News.com. July 10, 2008.

COMMENTARY

Overcoming barriers to the implementation of a pharmacy bar code scanning system for medication dispensing: a case study.

Nanji KC, Cina J, Patel N, Churchill W, Gandhi TK, Poon EG. J Am Med Inform Assoc. 2009;16:645-650.

NEWSPAPER/MAGAZINE ARTICLE

Dose of technology helps Shands at UF avoid drug errors.

Chun D. Gainsville Sun. August 21, 2006.

COMMENTARY

Shake Well.

Flynn EA. AHRQ WebM&M [serial online]. September 2003.

NEWSPAPER/MAGAZINE ARTICLE

Kaiser-Santa Clara hospital fined after baby's death: $25,000 penalty for Kaiser's drug error.

Ostrov BF. San Jose Mercury News. October 26, 2007;Local section:1B.

COMMENTARY

Workaround Error

Pape T. AHRQ WebM&M [serial online]. Febuary 2006.

STUDY

Cost-benefit analysis of a hospital pharmacy bar code solution.

Maviglia SM, Yoo JY, Franz C, et al. Arch Intern Med. 2007;167:788-794.

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:13-17.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:618-621.

COMMENTARY

XL or Smaller?

Kozer E. AHRQ WebM&M [serial online]. June 2003.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

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

COMMENTARY

The 2-Week Itch.

Cohen MR. AHRQ WebM&M [serial online]. April 2003.

STUDY

A multiple-drawer medication layout problem in automated dispensing cabinets.

Pazour JA, Meller RD. Health Care Manag Sci. 2012;15:339-354.

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.

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.

COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

COMMENTARY

Failure to Report

Spath PL. AHRQ WebM&M [serial online]. March 2007.

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