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Epidemiology of Errors and Adverse Events
PATIENT SAFETY PRIMERS
Never Events
Adverse Events after Hospital Discharge
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REVIEW
Year in review: medication mishaps in the elderly.
Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.
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.
STUDY
Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.
Lapane KL, Hughes CM, Daiello LA, Cameron KA, Feinberg J. J Am Geriatr Soc. 2011;59:1238-1245.
STUDY
Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.
Hansen RA, Cornell PY, Ryan PB, Williams CE, Pierson S, Greene SB. Pharmacoepidemiol Drug Saf. 2010;19:1087-1094.
AUDIOVISUAL
Panel Discussion: Error Proofing Your Pharmacy.
Woodcliff Lake, NJ: Drug Topics; 2007.
STUDY
Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System—MEADERS.
Hickner J, Zafar A, Kuo GM, et al. Ann Fam Med. 2010;8:517-525.
STUDY
Medication error reporting in nursing homes: identifying targets for patient safety improvement.
Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.
STUDY
Interrater agreement with a standard scheme for classifying medication errors.
Forrey RA, Pedersen CA, Schneider PJ. Am J Health Syst Pharm. 2007;64:175-181.
STUDY
Medication use leading to emergency department visits for adverse drug events in older adults.
Budnitz DS, Shehab N, Kegler SR, Richards CL. Ann Intern Med. 2007;147:755-765.
STUDY
A comparison of voluntarily reported medication errors in intensive care and general care units.
Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.
STUDY
Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.
Gurwitz JH, Field TS, Rochon P, et al. J Am Geriatr Soc. 2008;56:2225-2233.
STUDY
Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.
Vogelsmeier A, Scott-Cawiezell J. J Nurs Care Qual. 2011;26:236-242.
STUDY
Types, prevalence, and potential clinical significance of medication administration errors in assisted living.
Young HM, Gray SL, McCormick WC, et al. J Am Geriatr Soc. 2008 56:1199-1205.
STUDY
Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults.
Hayes BD, Klein-Schwartz W. Clin Toxicol (Phila). 2010;48:68-71.
STUDY
The safety of warfarin therapy in the nursing home setting.
Gurwitz JH, Field TS, Radford MJ, et al. Am J Med. 2007;120:539-544.
STUDY
Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany.
Gerber A, Kohaupt I, Lauterbach KW, Buescher G, Stock S, Lungen M. Am J Geriatr Pharmacother. 2008;6:212-219.
STUDY
Adverse drug events resulting from patient errors in older adults.
Field TS, Mazor KM, Briesacher B, Debellis KR, Gurwitz JH. J Am Geriatr Soc. 2007;55:271-276.
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.
NEWSPAPER/MAGAZINE ARTICLE
Mistakes, some deadly, haunt county jails.
Carter M. Seattle Times. March 9, 2007:A1.
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.
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