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Bates D. Jt Comm J Qual Patient Saf. 2006;32:667-671.
Dr. Gurwitz discusses his research on preventing adverse drug events in elderly patient populations.
Despite Clues, Failed to Rescue
Amir A. Ghaferi, MD, MS
Medication reconciliation: reducing risk for medication misadventure during transition from hospital to assisted living.
Fitzgibbon M, Lorenz R, Lach H. J Gerontol Nurs. 2013;39:22-29.
Therapeutic errors involving adults in the community setting: nature, causes and outcomes.
Taylor DM, Robinson J, MacLeod D, MacBean CE, Braitberg G. Aust N Z J Public Health. 2009;33:388-394.
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.
The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study.
Tipping B, Kalula S, Badri M. S Afr Med J. 2006;96:1255-1259.
2005 Annual Patient Safety and Health Information Technology Conference: Making the Health Care System Safer through Implementation and Innovation.
Agency for Healthcare Research and Quality. June 6-10, 2005.
Partnering with families and patient advocates: another line of defense in adverse event surveillance.
ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.
Medication Overload: America's Other Drug Problem.
Brownlee S, Garber J. Brookline, MA: Lown Institute; 2019.
Reclaiming the systems approach to paediatric safety.
Cheung R, Roland D, Lachman P. Arch Dis Child. 2019 Feb 23; [Epub ahead of print].
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Adverse Events, Near Misses, and Errors
Threats to patient safety in primary care reported by older people with multimorbidity: baseline findings from a longitudinal qualitative study and implications for intervention.
Hays R, Daker-White G, Esmail A, et al. BMC Health Serv Res. 2017;17:754.
Effect of therapeutic interchange on medication reconciliation during hospitalization and upon discharge in a geriatric population.
Wang JS, Fogerty RL, Horwitz LI. PLoS One. 2017;12:e0186075.
Development of a trigger tool to identify adverse drug events in elderly patients with multimorbidity.
Toscano Guzmán MD, Galván Banqueri M, Otero MJ, Alfaro Lara ER, Casajus Lagranja P, Santos Ramos B. J Patient Saf. 2017 Jun 14; [Epub ahead of print].
Learning from no-fault treatment injury claims to improve the safety of older patients.
Wallis KA. Ann Fam Med. 2015;13:472-474.
Accidental overdoses involving fluorouracil infusions.
ISMP Medication Safety Alert! Acute Care Edition. June 18, 2015;20:1:5.
Effects of skilled nursing facility structure and process factors on medication errors during nursing home admission.
Lane SJ, Troyer JL, Dienemann JA, Laditka SB, Blanchette CM. Health Care Manage Rev. 2014;39:340-351.
Older folks in hospitals: the contributing factors and recommendations for incident prevention.
Mansah M, Griffiths R, Fernandez R, Chang E, Thuy Tran D. J Patient Saf. 2014;10:146-153.
Validating administrative data for the detection of adverse events in older hospitalized patients.
Ackroyd-Stolarz S, Bowles SK, Giffin L. Drug Healthc Patient Saf. 2014;6:101-108.
Medicines management support to older people: understanding the context of systems failure.
Rogers S, Martin G, Rai G. BMJ Open. 2014;4:e005302.
MARQUIS Medication Reconciliation Resource Center.
Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). Philadelpha, PA: Society for Hospital Medicine.
Medication errors: prescriptions for safety.
Horowitz AC. Long-Term Living. December 6, 2013.
Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications.
Kanaan AO, Donovan JL, Duchin NP, et al. J Am Geriatr Soc. 2013;61:1894-1899.
Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals.
Ramsay AI, Turner S, Cavell G, et al. BMJ Qual Saf. 2014;23:136-146.
Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention.
Federal Register. Washington, DC: Office of Disease Prevention and Health Promotion. September 4, 2013;78:54469-54470.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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