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- Communication Improvement 2
- Education and Training 6
- Error Reporting and Analysis 2
- Human Factors Engineering 4
- Legal and Policy Approaches
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches 4
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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This article reports on an error for which criminal charges were filed against the pharmacist and his license was revoked, prompting concern from pharmacy experts that such action could discourage reporting.
Ostrov BF. San Jose Mercury News. October 26, 2007;Local section:1B.
This article reports that, despite facing state sanctions and fines for its role in three fatal medication errors since 2004, a violating hospital was slow to retrain its pharmacy technicians.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
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 > Commentary
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.
This monthly selection of reports includes errors involving epidural medication administered intravenously and mistaken reuse of discontinued drugs.
Young A. The Atlanta Journal-Constitution; September 20, 2009:B1.
This newspaper article reports on numerous prescription mistakes in retail pharmacies in Georgia and offers tips for consumers to help prevent errors with their medications.
Journal Article > Commentary
Anderson P, Townsend T. Amer Nurs Today. March 2010;5:23-27.
This commentary describes 10 elements that contribute to safe medication use and provides suggestions to embed them in daily nursing practice.
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.
Vedder T. Problem Solvers. KOMO 4 News. October 1, 2010.
This news piece discusses medication errors that led to adverse events in a Seattle children's hospital.