AHRQ Patient Safety Network

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Administration Errors

Origin/Sponsor

•Africa (1)

•Asia (12)

•Australia and New Zealand (12)

•Central and South America (4)

Resource Types

•Clinical Guideline (1)

•Journal Article (258)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newspaper/Magazine Article (44)

•Press Release/Announcement (11)

•Special or Theme Issue (5)

•Tools/Toolkit (4)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (107)

•Active Errors (133)

•Latent Errors (36)

•Near Miss (12)

Approach to Improving Safety

•Quality Improvement Strategies (88)

•Legal and Policy Approaches (21)

•Error Reporting and Analysis (86)

•Communication Improvement (41)

•Human Factors Engineering (90)

•Teamwork (5)

•Specialization of Care (16)

•Logistical Approaches (27)

•Culture of Safety (20)

•Technologic Approaches (101)

•Education and Training (73)

Clinical Areas

•Allied Health Services (1)

•Medicine (218)

•Nursing (104)

•Pharmacy (97)

Target Audience

•Health Care Providers (287)

•Health Care Executives and Administrators (272)

•Non-Health Care Professionals (102)

•Patients (24)

Setting of Care

•Hospitals (208)

•Psychiatric Facilities (4)

•Residential Facilities (13)

•Ambulatory Care (21)

•Outpatient Surgery (2)

•Patient Transport (3)

1 - 20 of 341

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NEWSPAPER/MAGAZINE ARTICLE

Design for reliability: barcoded medication administration.

Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.

STUDY

Effect of bar-code technology on the safety of medication administration.

Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.

REVIEW

Bar code technology and medication administration error.

Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.

STUDY

Effect of bar-code–assisted medication administration on medication administration errors and accuracy in multiple patient care areas.

Helmons PJ, Wargel LN, Daniels CE. Am J Health Syst Pharm. 2009;66:1202-1210.

STUDY

Severity of medication administration errors detected by a bar-code medication administration system.

Sakowski J, Newman JM, Dozier K. Am J Health Syst Pharm. 2008;65:1661-1666.

NEWSPAPER/MAGAZINE ARTICLE

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

COMMENTARY

Implementing a safe and reliable process for medication administration.

Richardson B, Bromirski B, Hayden A. Clin Nurse Spec. 2012;26:169-176.

REVIEW

Medication administration technologies and patient safety: a mixed-method systematic review.

Wulff K, Cummings GG, Marck P, Yurtseven O. J Adv Nurs. 2011;67:2080-2095.

STUDY

A network collaboration implementing technology to improve medication dispensing and administration in critical access hospitals.

Wakefield DS, Ward MM, Loes JL, O'Brien J. J Am Med Inform Assoc. 2010;17:584-587.

COMMENTARY classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

STUDY

Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds.

Miller DF, Fortier CR, Garrison KL. Ann Pharmacother. 2011;45:162-168.

COMMENTARY classic

Computerization can create safety hazards: a bar-coding near miss.

McDonald CJ. Ann Intern Med. 2006;144:510-516.

STUDY

Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience.

Westbrook JI, Rob MI, Woods A, Parry D. BMJ Qual Saf. 2011;20:1027-1034.

STUDY

The impact of type of manual medication cart filling method on the frequency of medication administration errors: a prospective before and after study.

Schimmel AM, Becker ML, van den Bout T, Taxis K, van den Bemt PM. Int J Nurs Stud. 2011;48:791-797.

STUDY

Improving patient safety by identifying side effects from introducing bar coding in medication administration.

Patterson ES, Cook RI, Render ML. J Am Med Inform Assoc. 2002;9:540-553.

STUDY

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.

STUDY

Prevalence of medication administration errors in two medical units with automated prescription and dispensing.

Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. J Am Med Inform Assoc. 2012;19:72-78.

STUDY

Improving insulin distribution and administration safety using Lean Six Sigma methodologies.

Yamamoto J, Abraham D, Malatestinic B. Hosp Pharm. 2010;45:212-224.

STUDY

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.

STUDY

Association of interruptions with an increased risk and severity of medication administration errors.

Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010;170:683-690.

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