• Errors in Medicine
• Adverse Drug Reactions and Adverse Drug Events
• Medication Errors
• Incidence and Prevalence of Medication Errors and Adverse Drug Events
• Medication Errors - Chemotherapy
• I.V. Medication Errors
• Monitoring, Reporting, and Tracking
• Automation and Technology
• Automation and Technology – Electronic Medical Records, CPOE, and Alerts
• Pharmacists’ Roles
• Leadership
• Medication Use Process
• Medication Use Process - Prescribing Errors
• Medication Use Process - Dispensing Errors
• Look-Alike Sound-Alike
• Sentinel Events
• Economic Impact
• Just Culture

Errors in Medicine

• Berwick DM, Leape LL. Reducing errors in medicine: It is time to take this more seriously. BMJ. 1999;319(7203):136-137.
• Leape LL, Berwick DM. Five years after To Err Is Human: What have we learned? JAMA 2005;293(19):2384–2390.
• Manasse HR. Medication use in an imperfect world: Drug Misadventuring as an Issue of Public Policy. part 1. Am J Hosp Pharm. 1989;46:929-944.
• Manasse HR. Medication Use in an Imperfect World: Drug Misadventuring as an Issue of Public Policy. Part 2. Am J Hosp Pharm. 1989;46:1141-1152.
• Myers CE. Medication misadventures: A policy of openness and learning. Am J Heath-Syst Pharm.; 56(9):863.
• Ovretveit J, Bate P, Cleary P, et al. Quality collaboratives: lessons from research. Qual Safety Health Care. 2002;11:345-351.

Adverse Drug Reactions and Adverse Drug Events

• Bates DW. Drugs and adverse reactions: how worried should we be? JAMA. 1998;279(15):1216-1217.
• Gholami K, Shalviri G. Factors associated with preventability, predictability and severity of adverse drug reactions. Ann Pharmocother. 1999;33236-240.
• Golz G, Fitchett L. Nurses' perspective on a serious adverse drug event. Am J Health-Syst Pharm. 1999;56):904-907.
• Leape LL. Preventing adverse drug events. Am J Health-Syst Pharm. 1995;52(4):379-382.
• Leape LL, Bates DW, Cullen DJ et al for the ADE prevention group. Systems analysis of adverse drug events. JAMA. 1995;274(1):35-43.
• Nebeker JR, Barach P, Samore MH. Clarifying adverse drug events: A clinician’s guide to terminology, documentation, and reporting. Ann Intern Med. 2004; 140(10): 795-801.
• Seeger JD, Kong SX, Schumock GT. Characteristics associated with ability to prevent adverse drug reactions in hospitalized patients. Pharmacotherapy. 1998;18(6):1284-1289.

Medication Errors

• Allan EL, Barker KN. Fundamentals of medication error research. Am J Hosp Pharm. 1990;47:555-571.
• Cohen MR. Cooperative approaches to medication error management. Top Hosp Pharm Manage. 1991;11(Apr):53-65.
• Cohen MR, Senders J, Davis NM. Failure mode and effects analysis: A novel approach to avoiding dangerous medication errors and accidents. Hosp Pharm. 1994; 29(4): 319-330
• Coleman IC. Medication errors: Picking up the pieces. Drug Top. 1999;1483-92.
• Hasegawa GR. Responsibility for medication errors. Am J Heath Syst Pharm. 1999;56(3):215.
• Hellier, E., et al., Considering the impact of medicine label design characteristics on patient safety. Ergonomics, 2006. 49(5-6): p. 617-30.
• Tucker LL, Cohen MR, Davis NM. Orientation teaching tool to prevent medication error. Hosp Pharm. 1994;29(11):984,986-988,991.

Incidence and Prevalence of Medication Errors and Adverse Drug Events

• Barker KN, Flynn EA, Pepper GA, et al. Medication errors observed in 36 health care facilities. Arch Intern Med 2002;162:1897-1903.
• Bates DW, Cullen DJ, Laird N. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1):29-34.
• Brennan TA, Leape LL, Laird NM et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-376.
• Cohen MR, Proulx SM, Crawford SY. Survey of hospital systems and common serious medication errors.  J Healthcare Risk Manage. 1998 (Winter);18(1):16-27.
• Couris RR, Tataronis GR, DePietro SL, DeBellis RA, Young CR for the Massachusetts Board of Registration in Pharmacy. Medication Error Study. Boston, MA: Division of Registration, Commonwealth of Massachusetts. 1999.
• Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med. 1997;25(8):1289-97.
• Dean BS, Allan EL, Barber ND, Barker KN. Comparison of medication errors in an American and a British hospital. Am J Health-Syst Pharm. 1995;522543-2549.
• Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older adults in the ambulatory setting. JAMA. 2003;289:1107-1116.
• Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric in patients. JAMA 2001; 285:2114-2120.
• Knudsen P, Herborg H, et al. Preventing medication errors in community pharmacy: frequency and seriousness of medication errors. Qual Saf Health Care. 2007;16:291-296.
• Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279(15):1200-1205.
• Phillips J, Beam S, Brinker A, Holquist C, Honic P, Lee LY, Pamer C. Retrospectrive analysis of mortalities associated with medication errors. Am J Health-Syst Pharm. 2001; 58:1835-1841.
• Thomas EJ, Brennan TA. Incidence and types of preventable adverse events in elderly patients: population based review of medical records. British Medical Journal 2000; 320:741-744.

I.V. Medication Errors

• Adachi, W. and A.E. Lodolce. Use of failure mode and effects analysis in improving the safety of i.v. drug administration. Am J Health Syst Pharm, 2005. 62(9): p. 917-20.
• ASHP Reports. Proceedings of a summit on preventing patient harm and death from i.v. medication errors. July 14–15, 2008. Rockville, Maryland. Am J Health-Syst Pharm. 2008; 65:2367-79
• Eskew JA, Jacobi J, Buss WF, et al. Using innovative technologies to set new safety standards for the infusion of intravenous medications. Hosp Pharm. 2002; 37:1179-1189.
• Nicholas, P.K., Toward Safer IV Medication Administration. AJN, 2005. Supplement: p. 25-30.
• Sanborn MD, Moody ML, Harder KA et al.  Second consensus development conference on the safety of intravenous drug delivery systems- 2008. Am J Heath-Syst Pharm. 2009; 66:185-92.

Medication Errors - Chemotherapy

• Cohen MR, Anderson RW, Attilio RM et al. Preventing medication errors in cancer chemotherapy. Am J Health-Syst Pharm. 1996;53737-746.
• Goldspiel BR, DeChristoforo R, Daniels CE. Continuous-improvement approach for reducing the number of chemotherapy-related medication errors. Am J Health-Syst Pharm. 2000; 57:S4-S9.

Monitoring, Reporting, and Tracking

• Cohen MR. Why error reporting systems should be voluntary. BMJ. 2000;320(7237):728-729.
• Colodny L, Spillane J. Toward increased reporting of adverse drug reactions. Hosp Pharm. 1999;34:1179-1185.
• Handler SM, Nace DA, Studenski SA, et al. Medication error reporting in long-term care. Am J Geriatr Pharmacother 2004;2(3):190–196.
• Maliekal J, Thorton J, . A description of a successful computerized adverse drug reaction tracking program. Hosp Formul. 1990;25(4): 436-9, 442
• Betz RP, Levy HB. An interdisciplinary method of classifying and monitoring medication errors. Am J Hosp Pharm. 1985;42(8):1724-1732.
• Dean BS, Barber ND. A validated, reliable method of scoring the severity of medication errors. Am J Health-Syst Pharm. 1999 56(1):57-62.
• Dunn EB, Wolfe JJ. Medication error classification and avoidance. Hosp Pharm. 1997;32:860-865.
• Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002;59(5):436 – 446.
• Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care 2003; 12:194-200.
• Santell JP, Hicks RW, McMeekin J, Cousins DD. Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol 2003;43(7):760–767.
• Savage SW, Schneider PJ, Pedersen CA. Utility of an online medication- error-reporting system. Am J Health Syst Pharm 2005;62(21):2265–2270.
• Schneider PJ, Hartwig SC. Use of severity-indexed medication error reports to improve quality. Hosp Pharm. 1994;29(3):205-6,208-211.

Automation and Technology

• Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003;348(25):2526–2534.
• Bates DW. Using information technology to reduce rates of medication errors in hospitals. BMJ 2000; 320(7237): 788-791.
• Borel JM, Rascati KL. Effect of an automated, nursing unit-based drug-dispensing device on medication errors. Am J Health-Syst Pharm. 1995;52(17):1875-1879.
• Hammond J, Bermann M, Chen B, et al. Incorporation of a computerized human patient simulator in critical care training: a preliminary report. J Trauma. 2002;53:1064-1067.
• Kaushal R, Bates DW. Information technology and medication safety: What is the benefit? Quality & Safety in Health Care 2002; 11:261-265.
• Means BJ, Derewicz HJ, Lamy PP. Medication errors in a multidose and a computer-based unit dose drug distribution system. Am J Hosp Pharm. 1975;32(2):186-91.
• Neuenschwander M. Limiting or increasing opportunities for errors with dispensing automation. Hosp Pharm. 1996;31:1102-1106.
• Schneider PJ. A review of the safety of intravenous drug delivery systems. Hosp Pharm. 1999;34:1044-1056.

Automation and Technology - Electronic Medical Records, CPOE, and Alerts

• Bates DW, Teich JM, Lee J et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6:313-21.
• Bates DW, Leape LL, Cullen, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(15):1311-1316.
• Bates DW, Ebell M, Gotlieb E, et al. Proposal for electronic medical records in U.S. primary care. J Am Med Inf Assoc. 2003;10:1-10.
• Raschke RA, Gollihare B, Wunderlich TA, Guidry JR, Leibowitz AI, Peirce JC et al. A computer alert system to prevent injury from adverse drug events. JAMA. 1998;280(15):1317-1320.
• Schiff GD, Rucker TD. Computerized prescribing: building the electronic infrastructure for better medication usage. JAMA. 1998;279(13):1024-1029.

Pharmacists’ Roles

• Blum KV, Abel SR, Urbanski CJ, Pierce JM. Medication error prevention by pharmacists. Am J Hosp Pharm. 1988;45(9):1902-1903.
• Cavuto NJ, Woosley RL, Sale M. Pharmacies and the prevention of fatal drug interactions. JAMA. 1996;275(14):1086-1087.
• Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, Bates DW. Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit. JAMA. 1999;282(3):267-270.
• Manasse HR. Pharmacists and the quality-of-care imperative. Am J Health-System Pharm. 2000 ;57(12):1170-1172.
• Sellers JA. Too many medication errors, not enough pharmacists. Am J Health-System Pharm. 2000 57;:337.
• Weideman RA, Bernstein IH, McKinney WP. Pharmacist recognition of potential drug interactions. Am J Health-Syst Pharm. 1999 1;56:1524-1529.

Leadership

• Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK. Patient safety leadership walkrounds. Jt Comm J Qual Safety. 2003;29:16-26.
• Kowiatek JG, Weber RJ, Skledar SJ, Sirio CA. Medication safety manager in an academic medical center. Am J Health Syst Pharm. 2004;61:58-64.
• Mark S. Developing a Medication Patient Safety Program – Infrastructure and Strategy. Hospital Pharmacy. 2007;42(2):149-156 (Available at: http://www.factsandcomparisons.com/assets/hpdatenamed/20070201_feb2007_dirform.pdf)
• Mark S, Weber RJ. Developing a medication patient safety program, part 2: process and implementation. Hosp Pharm. 2007; 42(3): 249-254.
• McCarthy ID, Cohen MR, Kateiva J, McAllister JC, Ploetz PA. What should a pharmacy manager do when a serious medication error occurs? A panel discussion. Am J Hosp Pharm. 1992;49(16):1405-1412.
• Phillips, M.A., Institutionwide medication safety program. Am J Health Syst Pharm, 2003. 60(21): p. 2198-200.
• Sanks RJ. A pharmacy manager's perspective on a serious adverse drug event. Am J Health-Syst Pharm. 1999 ;56:907-909.
• Schneider PJ. Five worthy aims for pharmacy's clinical leadership to pursue in improving medication use. Am J Health-Syst Pharm. 1999;56:2549-2552.

Medication Use Process

• Dang D; Feroli RE; Gill C; Paine L; Shermock K; Suflita J; Walrath JM. Quest for the Ideal: A Redesign of the Medication Use System. Journal of Nursing Care Quality. 2007;22(1):11-19.
• Kelly W, Rucker D. Compelling features of a safe medication-use system. Am J Health Syst Pharm. 2006; 63:1461-8.
• Ryan KD. Driving fear out of the medication-use process so that improvement can occur. Am J Heath-Syst Pharm. 1999;56(17):1765-1769.
• Schneider PJ. Creating an environment for improving the medication-use process. Am J Heath-Syst Pharm. 1999;56(17):1769-1972.

Medication Use Process - Prescribing Errors

• Bryony D, Schachter M, Vincent C et al.  Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 2002; 359: 1373-1378.
• Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997 ;277(4):312-317.
• Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med. 1997;157(14):1569-1576.
• Lesar TS. Tenfold medication dose prescribing errors. Ann Pharmacother. 2002;36:1833-1839.

Medication Use Process - Dispensing Errors

• Bond CA, Raehl CL. Pharmacist assessment of dispensing errors: risk factors, practice sites, professional functions, and satisfaction. Pharmacotherapy. 2001;21:614-626.
• Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc. 2003;43:191-200.
• Kistner UA, Keith MR, Sergeant KA, Hokanson JA. Accuracy of dispensing in a high-volume, hospital-based outpatient pharmacy. Am J Hosp Pharm. 1994;51(22): 2793-7.

Look-Alike Sound-Alike

• Davis NM. Drug names that look and sound alike. Hosp Pharm. 1999;341160-1174.
• Lambert BL. Predicting look-alike and sound-alike medication errors. Am J Health-Syst Pharm. 1997;54(10):1161-1171.

Sentinel Events

• Henry TR, Azuma L, Shaban HM. Learning and process improvement after a sentinel event. Hosp Pharm. 1999;34 839-844.
• Hutchinson D. Getting to the bottom of a sentinel event. Am J Health-Syst Pharm. 1999;56(30):2031-2032.

Economic Impact

• Bates DW, Spell N, Cullen DJ et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277(4):307-11.
• Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1997; 277(4):301-306.
• Johnson JA, Bootman JL. Drug-related morbidity and mortality and the economic impact of pharmaceutical care. Am J Health-Syst Pharm. 1997;54(5):554-8.
• Johnson JA, Bootman JL. Drug-Related Morbidity and Mortality: A Cost-of-Illness Model. Arch Intern Med. 1995; 155(18):1949-1956.
• Rothschild JM, Federico FA, Gandhi TK. Analysis of medication-related malpractice claims: Causes, preventability, and costs. Arch Intern Med 2002; 162:2414-2420.
• Schneider PJ, Gift MG, Lee YP, Rothermich EA, Sill BE. Cost of medication-related problems at a university hospital. Am J Health-Syst Pharm. 1995;52(21):2415-2418.

Just Culture

• Smetzer JL, Cohen MR. Lessons from the Denver medication error/criminal negligence case: Look beyond blaming individuals. Hosp Pharm. 1998;33:640-657.