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- Communication Improvement 7
- Education and Training 9
- Error Reporting and Analysis 2
- Human Factors Engineering 3
- Legal and Policy Approaches 8
- Logistical Approaches 2
- Quality Improvement Strategies 5
- Specialization of Care 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Drug shortages 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 19
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Cases & Commentaries
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; May 2002. AHRQ Publication No. 01-0040c.
This Web site suggests questions that all patients should ask a physician, nurse, and/or pharmacist when they receive a medication prescription.
Bull G. USA Today. April 28, 2005.
This article reports on Target pharmacies' redesign of prescription bottles. The new bottles, designed to support safer outpatient medication use, have a flattened label and are color-coded for each family member.
Journal Article > Study
Stewart D, Helms P, McCaig D, Bond C, McLay J. Br J Clin Pharmacol. 2005;59:677-683.
The investigators issued questionnaires to parents in seven community pharmacies to prospectively monitor pediatric adverse drug reactions (ADRs). They found that the system was effective for reporting ADRs.
Trebilcock B. Good Housekeeping. June 2005;240:67-68,72.
This article reports on the types of errors that occur in community pharmacies and provides recommendations for consumers to reduce their risk.
Chase M. Wall Street Journal. August 16, 2005:D1.
This article reports that in other countries, some medications have the same brand name as U.S. medications but contain completely different ingredients, often for treatment of different conditions. To avoid mix-ups, the article cautions against purchasing prescription medications abroad.
Fargen J. Boston Herald. April 22, 2007.
This article reports on a decrease in consumer complaints following improvements made by community pharmacies in Massachusetts.
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.
McCoy K, Brady E. USA Today. February 11, 2008:A1.
This series of investigative articles uncovers the factors involved in pharmacy errors, relates stories of patients harmed by such errors, and includes steps that consumers can take to minimize their risk.
Haiken M. Caring.com. August 17, 2009.
To help consumers use medications safely, this article describes 10 common medication mistakes and provides tips on how effective communication and clarification can prevent them.
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.
Ross B. ABC News. March 1, 2010.
This video news story discusses medication errors in retail pharmacies. The piece investigates how the lack of training standards for pharmacy technicians and the presence of production pressures contribute to such errors.
Haythorn R. ABC News. February 7, 2011.
This video news segment reports on a pharmacy error involving similar patient names. A pregnant woman was mistakenly given a chemotherapy medication instead of an antibiotic.
Audiovisual > Audiovisual Presentation
Gill L. Consumer Reports Health. June 2011.
This video reports on a sampling of prescriptions from major retail pharmacies that demonstrated gaps, inconsistencies, and lack of clarity in drug information distributed to patients with their medications.
Sun LH. Washington Post. April 10, 2012.
This newspaper article discusses strategies hospitals are using to address drug shortages.
LaGrone K. WPTV.com. April 30, 2012.
This news piece discusses pharmacy medication dispensing errors and describes how patients can help prevent them.
Serious adverse events from accidental ingestion by children of over-the-counter eye drops and nasal sprays.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 25, 2012.
This announcement raises awareness of risks associated with children accidentally ingesting over-the-counter eye drops and nasal sprays.
Tools/Toolkit > Fact Sheet/FAQs
Horsham, PA: Institute for Safe Medication Practices; 2018.
This set of leaflets provides patients with information about taking high-alert medications safely.
ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
This newsletter article describes an incident involving a patient who noticed that the tablets in her prescription refill had a different marking than usual, alerting her that she might have received an incorrect medication which was confirmed by the pharmacist. Tips for patients to avoid medication errors include being familiar with how their medicines look and checking prescriptions before leaving the pharmacy. Practitioners can help prevent these errors by counting and labeling prescriptions one at a time and performing patient consultations.