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ISMP Medication Safety Alert! Acute Care Edition. May 19, 2005;10:1-2.
A survey of 1572 nurses, pharmacists, and physicians revealed that blame, shame, and fear of punishment still affect the reporting behaviors of practitioners.
VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.
Washington, DC: United States Government Accountability Office; May 2006. Publication GAO-06-544.
This investigation determined that the U.S. Veterans Administration has taken steps to improve the reliability of their practitioner licensure and certification screening processes for employees and new hires but found that some weaknesses still exist.
Fernandez J. Drug Topics. May 7, 2007.
This article discusses a chemotherapy overdose that led to a child's death and the punitive measures taken against the pharmacist involved.
Dworkin A. The Oregonian. June 20, 2007:A01.
This article reports on dispensing errors made by Oregon pharmacists and the fines imposed as penalty for those errors.
Levy S. Drug Topics. July 9, 2007.
This article reports on ways in which chain pharmacies are improving the reliability of medication dispensing, such as better training for pharmacy employees and use of technology.
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.
Paul R. Drug Topics. September 17, 2007;151:10.
This article reports on an error for which criminal charges were filed against the pharmacist and his license was revoked, prompting concern from pharmacy experts that such action could discourage reporting.
ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.
Reporting that recalled medications were found in hospital pharmacies, this article describes recommendations to improve the process for removing recalled products.
Journal Article > Study
Holdsworth M, Wittstrom K, Yeitrakis T. Ann Pharmacother. 2013;47:475-481.
The majority of state licensing boards pursue disciplinary action, such as license suspension, against pharmacists who are involved in medication errors. This occurs despite a consensus that such punitive measures are unlikely to improve patient safety.