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- Communication Improvement 15
- Education and Training 8
- Error Reporting and Analysis 5
- Human Factors Engineering 3
- Legal and Policy Approaches 3
- Logistical Approaches 1
- Quality Improvement Strategies 7
- Technologic Approaches 7
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Errors/Preventable Adverse Drug Events 20
- Health Care Executives and Administrators 6
Health Care Providers
- Nurses 6
- Physicians 18
- Non-Health Care Professionals 3
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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.
McNeil Consumer & Specialty Pharmaceuticals announces nationwide recall of Children's Tylenol Meltaways - 80 Mg, Children's Tylenol Softchews - 80 Mg and Jr. Tylenol Meltaways - 160 Mg [press release].
Fort Washington, PA: McNeil Consumer & Specialty Pharmaceuticals; June 3, 2005.
This news release announces the recall of several Tylenol children's medications. The packaging and labeling for these medications may be confusing and lead to overdosing.
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.
Rados C. FDA Consum. 2005;39:35-37.
This article reports on problems with drug names, the naming process for medications, and both industry and consumer actions that can minimize misunderstandings.
FDA Public Health Advisory. Silver Spring, MD: US Food and Drug Administration; December 21, 2007.
This Food and Drug Administration public health advisory alerts health care professionals, patients, and their caregivers to the possibility for overdoses of fentanyl in patients using fentanyl skin patches for pain control.
ISMP Medication Safety Alert! Acute Care Edition. June 30, 2005;10.
This alert cautions against the use of automated medication-refill kiosks.
Cohen B. "Morning Edition." National Public Radio. August 1, 2005.
This audio segment reports on a new prescription bottle that allows physicians and pharmacists to record verbal instructions, which patients can then retrieve by pushing a button on the bottle.
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.
Franklin D. New York Times. October 25, 2005:F1.
This article discusses an important health literacy and medication safety concern: the absence of standardization of colored warning labels applied to prescription bottles. Inconsistent messages, icons, and colors may cause confusion for consumers.
Tools/Toolkit > Fact Sheet/FAQs
Vienna, VA: The Partnership for Safe Medicines; 2005.
This checklist will help patients determine if medications are possibly counterfeit, and it explains how to report problems.
Consumers Filling U.S. Prescriptions Abroad May Get the Wrong Active Ingredient Because of Confusing Drug Names.
FDA Public Health Advisory [US Food and Drug Administration Web site]. January 2006.
This U.S. Food and Drug Administration advisory alerts clinicians and consumers to potential mistakes in prescriptions purchased abroad. The advisory includes a table of medications known to contain different active ingredients when purchased outside the United States.
Journal Article > Study
Sharif I, Lo S, Ozuah PO. J Health Care Poor Underserved. 2006;17:65-69.
The authors surveyed pharmacies in the Bronx, New York, and found that 69% could provide prescription labels in Spanish, and that most used a computer program to translate the labels.
Institute for Healthcare Improvement Web site. March 20, 2006.
This article reviews the importance of medication reconciliation, discusses the difficulties of building the process into patient care, and shares stories from hospitals that have successfully implemented programs.
Journal Article > Study
Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research.
Brown M, Frost R, Ko Y, Woosley R. Patient Educ Couns. 2006;62:302-315.
Chun D. Gainsville Sun. August 21, 2006.
This article describes a computerized drug ordering and dispensing system at a Florida hospital.
Foreman J. Los Angeles Times. September 4, 2006:F3.
This article describes what patients can do to minimize opportunities for medication error.
Brody JE. New York Times. January 2, 2007:F7.
This article discusses some common medication errors that consumers can avoid by asking the right questions and being familiar with prescriptions and the proper directions for taking them.
Journal Article > Commentary
Pollock M, Bazaldua OV, Dobbie AE. Am Fam Physician. 2007;75:231-236, 239-240.
The authors expand on an internationally recognized process for good prescribing by suggesting additional steps—considering drug costs and using technology to minimize medication error.
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.