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Medication Use Safety Resources

Online Tools and Resources

Tools


Recommended Reading

Book and Bibliography of Patient Safety Articles

Adverse Drug Reactions and Adverse Drug Events

Bibliography

  • Kanaan AO, Donovan JL, Duchin NP, et al. Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers Criteria Medications. J Am Geriatr Soc. 2013 Nov;61(11):1894-9. PubMed PMID: 24116689
  • Krähenbühl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J, Krähenbühl S. Drug-related problems in hospitals: a review of the recent literature. Drug Saf. 2007;30(5):379-407. Review. PubMed PMID: 17472418
  • Thomsen LA, Winterstein AG, Søndergaard B, Haugbølle LS, Melander A. Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Ann Pharmacother. 2007 Sep;41(9):1411-26. PubMed PMID: 17666582
  • Cresswell KM, Fernando B, McKinstry B, Sheikh A. Adverse drug events in the elderly. Br Med Bull. 2007;83:259-74. PubMed PMID: 17580312
  • Rommers MK, Teepe-Twiss IM, Guchelaar HJ. Preventing adverse drug events in hospital practice: an overview.Pharmacoepidemiol Drug Saf. 2007 Oct;16(10):1129-35. PubMed PMID: 17610221
  • Routledge PA, O'Mahony MS, Woodhouse KW. Adverse drug reactions in elderly patients. Br J Clin Pharmacol. 2004 Feb;57(2):121-6. PubMed PMID: 14748810
  • Chang A, Schyve PM, Croteau RJ, O'Leary DS, Loeb JM. The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care. 2005; 17: 95-105. PubMed PMID: 15723817
  • Armor BL, Bulkley C. English as a second language is a risk for an adverse drug event. J Patient Saf. 2014;10(4):231-2. PubMed PMID: 24522225
  • O'Connor M, Grissinger M. An Analysis of Reported Adverse Drug Reactions. Pa Patient Saf Advis. 2014 Jun;11(2):61-8.

Other Resources

  • ISMP QuarterWatch: Monitoring FDA MedWatch Reports
  • Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011.

Clinical Informatics in Medication Safety

Books

  • Phelps PK, ed. Smart Infusion Pumps: Implementation, Management, and Drug Libraries.2nd edition. Bethesda, MD: American Society of Health-System Pharmacists; 2016. ISBN: 978-1-58528-513-6
  • Wachter R. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age. New York, NY: McGraw-Hill Education; 2015. ISBN: 0201571849467

Bibliography

  • Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood). 2011 Mar;30(3):464-71. PubMed PMID: 21383365
  • van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006 Mar-Apr;13(2):138-47. PubMed PMID: 16357358
  • Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med. 2003 Jun 23;163(12):1409-16. PubMed PMID: 12824090
  • Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med. 2003 Jul 1;139(1):31-9. PubMed PMID: 12834316
  • Allison GM, Weigel B, Holcroft C. Does electronic medication reconciliation at hospital discharge decrease prescription medication errors? Int J Health Care Qual Assur. 2015;28(6):564-73. PubMed PMID: 26156431
  • Leung AA, Denham CR, Gandhi TK, et al. A Safe Practice Standard for Barcode Technology. J Patient Saf. 2015 Jun;11(2):89-99. PubMed PMID: 24618650
  • Avery AJ, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet. 2012;379:1310-1319. PubMed PMID:22357106
  • Forni A, Chu HT, Fanikos J. Technology utilization to prevent medication errors. Curr Drug Saf. 2010 Jan;5(1):13-8. PubMed PMID: 20210714
  • Schnipper JL, Hamann C, Ndumele CD, et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. Arch Intern Med. 2009 Apr 27;169(8):771-80.  PubMed PMID: 19398689
  • Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008 Jul-Aug;15(4):408-23. PubMed PMID: 18436903
  • Mahoney CD, Berard-Collins CM, Coleman R, Amaral JF, Cotter CM. Effects of an integrated clinical information system on medication safety in a multi-hospital setting. Am J Health Syst Pharm. 2007 Sep 15;64(18):1969-77. PubMed PMID: 17823111
  • Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle JF. High rates of adverse drug events in a highly computerized hospital. Arch Intern Med. 2005 May 23;165(10):1111-6. PubMed PMID: 15911723
  • Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med. 2005 Mar;33(3):533-40. PubMed PMID: 15753744

Other Resources

  • Bates DW, Evans RS, Murff H, Stetson PD, Pizziferri L, Hripcsak G. Detecting adverse events using information technology. J Am Med Inform Assoc. 2003 Mar-Apr;10(2):115-28. PubMed PMID: 12595401

Communication Failures

Bibliography

  • Berger JT, Sten MB, Stockwell DC. Patient handoffs: Delivering content efficiently and effectively is not enough. Int J Risk Saf Med. 2012;24(4):201-5. PubMed PMID: 23135334
  • Armor BL, Bulkley C. English as a second language is a risk for an adverse drug event. J Patient Saf. 2014;10(4):231-2. PubMed PMID: 24522225
  • Kannan L, Blocher N. Cultural Impact on Medication Instructions: The Case of the Turkish Teaspoon. J Patient Saf. 2015. PubMed PMID: 25828054
  • Callinan SM, Brandt NJ. Tackling Communication Barriers Between Long-Term Care Facility and Emergency Department Transfers to Improve Medication Safety in Older Adults. J Gerontol Nurs. 2015; 41(7):8-13. PubMed PMID: 26126025
  • Smith KJ, Handler SM, Kapoor WN, Martich GD, Reddy VK, Clark S. Automated Communication Tools and Computer-Based Medication Reconcilliation to Decrease Hospital Discharge Medication Errors. Am J Med Qual. 2015;pii: 1062860615574327. [Epub ahead of print] PubMed PMID: 25753453

Disclosure

Bibliography

  • O'Connor E, Coates HM, Yardley IE, Wu AW. Disclosure of patient safety incidents: a comprehensive review. Int J Qual Health Care. 2010 Oct;22(5):371-9. PubMed PMID: 20709703
  • Gallagher TH, Bell SK, Smith KM, Mello MM, McDonald TB. Disclosing harmful medical errors to patients: tackling three tough cases. Chest. 2009 Sep;136(3):897-903. PubMed PMID: 19736193
  • Boyle D, O'Connell D, Platt FW, Albert RK. Disclosing errors and adverse events in the intensive care unit. Crit Care Med. 2006 May;34(5):1532-7. PubMed PMID: 16540948
  • Leone D, Lamiani G, Vegni E, Larson S, Roter DL. Error disclosure and family members' reactions: does the type of error really matter? Patient Educ Cous. 2014 Apr;98(4):446-52. PubMed PMID: 25630608
  • Sukalich S, Elliott JO, Ruffner G. Teaching medical error disclosure to residents using patient-centered simulation training. Acad Med. 2014 Jan; 89(1):136-43. PubMed PMID 24280843
  • Kachalia A, Bates DW. Disclosing medical errors: the view from the USA. Surgeon. 2014 Apr; 12(2):64-7. PubMed PMID 24461211
  • Leape LL. Full disclosure and apology - an idea whose time has come. Physician Exec. 2006 Mar-Apr;32(2):16-8. PubMed PMID: 16615398

Economic Impact

Bibliography

  • Hug BL, Keohane C, Seger DL, Yoon C, Bates DW. The costs of adverse drug events in community hospitals. Jt Comm J Qual Patient Saf. 2012 Mar;38(3):120-6. PubMed PMID: 22435229
  • Paradis AR, Stewart VT, Bayley KB, Brown A, Bennett AJ. Excess cost and length of stay associated with voluntary patient safety event reports in hospitals. Am J Med Qual. 2009 Jan-Feb;24(1):53-60. PubMed PMID: 19139464
  • Pinilla J, Murillo C, Carrasco G, Humet C. Case-control analysis of the financial cost of medication errors in hospitalized patients. Eur J Health Econ. 2006 Mar;7(1):66-71. PubMed PMID: 16369841
  • Lassetter JH, Warnick ML. Medical errors, drug-related problems, and medication errors: a literature review on quality of care and cost issues. J Nurs Care Qual. 2003 Jul-Sep;18(3):175-81; quiz 182-3.PubMed PMID: 12856901
  • 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 Jan 22-29;277(4):307-11. PubMed PMID: 9002493

Errors in Medicine and Human Error

Bibliography

  • Royal S, Smeaton L, Avery AJ, Hurwitz B, Sheikh A. Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis. Qual Saf Health Care. 2006 Feb;15(1):23-31. PubMed PMID: 16456206
  • Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Morlock LL. Defining and measuring patient safety. Crit Care Clin. 2005 Jan;21(1):1-19, vii. PubMed PMID: 15579349
  • Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005 Aug 30;173(5):510-5. PubMed PMID: 16129874
  • Leape LL. Error in medicine. JAMA. 1994; 272: 1851-7. PubMed PMID: 7503827
  • Reason J. Human error: models and management. BMJ. 2000; 320: 768-70. PubMed PMID: 10720363
  • Reason J. Understanding adverse events: human factors. Qual Health Care. 1995; 4: 80-9. PubMed PMID: 10151618
  • Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002; 12: 1933-40. PubMed PMID: 12477944

Event Detection

Bibliography

  • Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995; 21: 541-8. PubMed PMID: 8556111
  • Hartnell N, Mackinnon N, Sketris I, Fleming M. Identifying, understanding, and overcoming barriers to medication error reporting in hospitals: a focus group study. BMJ Qual Saf. 2012; 21: 361-8. PubMed PMID: 22389018
  • Hazell L and Shakir SA. Under-reporting of adverse drug reactions: a systematic review. Drug Saf. 2006; 29: 385-96. PubMed PMID: 16689555
  • Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Systematic review of medication safety assessment methods. Am J Health Syst Pharm. 2011; 68: 227-40. PubMed PMID: 21258028
  • Naessens JM, Campbell CR, Huddleston JM, et al. A comparison of hospital adverse events identified by three widely used detection methods. Int J Qual Health Care. 2009; 21: 301-7. PubMed PMID: 19617381
  • Thomas EJ and Peterson LA. Measuring errors and adverse events in health care. J Gen Intern Med. 2003; 18: 61-7. PubMed PMID: 12534766
  • Ferranti J, Horvath MM, Cozart H, Whitehurst J, Eckstrand J. Reevaluating the safety profile of pediatrics: a comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment. Pediatrics. 2008; 121: e1201-7. PubMed PMID: 18450863
  • Classen DC, Pestotnik SL, Evans RS, Burke JP. Description of a computerized adverse drug event monitor using a hospital information system. Hosp Pharm. 1992; 27: 774, 776-9, 783. PubMed PMID: 10121426
  • Koppel R, Leonard CE, Localio AR, Cohen A, Auten R, Strom BL. Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system. J Am Med Inform Assoc. 2008; 15: 461-5. PubMed PMID: 18436910
  • Mitchell I, Schuster A, Smith K, Pronovost P, Wu A. Patient Safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human'. BMJ Qual Saf. 2015;pii:bmjqs-2015-004405.  PubMed PMID: 26217037
  • Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002; 59: 436-46. PubMed PMID: 11887410
  • Barker KN, Flynn EA, Pepper GA. Observation method of detecting medication errors. Am J Health Syst Pharm. 2002; 59: 2314-6. PubMed PMID: 12489369
  • Olsen S, Neale G, Schwab K, et al. Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Qual Saf Health Care. 2007; 16: 40-4. PubMed PMID: 17301203
  • Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ. 2007; 334: 79. PubMed PMID: 17175566
  • Weissman JS, Schneider EC, Weingart SN, et al. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? Ann Intern Med. 2008; 149: 100-8. PubMed PMID: 18626049
    Dormann H, Meth-Selbach U, Krebs S, et al. Incidence and costs of adverse drug reactions during hospitalisation: computerised monitoring versus stimulated spontaneous reporting. Drug Saf. 2000; 2: 161-8. PubMed PMID: 10672897
  • O'Neil AC, Peterson LA, Cook EF, Bates DW, Lee TH, Brennan TA. Physician reporting compared with medical record review to identify adverse medical events. Ann Intern Med. 1993; 119: 370-6. PubMed PMID: 8338290
  • Shojania KG. The frustrating case of incident-reporting systems. Qual Saf Health Care. 2008; 17: 400-2.  PubMed PMID: 19064653
  • Westbrook JI, Li L, Lehnbom EC, et al. What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. Int J Qual Health Care. 2015; 27: 1-9. PubMed PMID: 25583702
  • Gandhi TK, Seger DL, Bates DW. Identifying drug safety issues: from research to practice. Int J Qual Health Care. 2000; 12: 69-76. PubMed PMID: 10733086
  • Morimoto T, Gandhi TK, Seger AC, Hsieh TC, Bates DW. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care. 2004; 13: 306-14. PubMed PMID: 15289635
  • Raschke RA, Gollihare B, Wunderlich TA, et al. A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital. JAMA. 1998; 280: 1317-20. PubMed PMID: 9794309
  • Bates DW, Evans RS, Murff H, Stetson PD, Pizziferri L, Hripcsak G. Detecting adverse events using information technology. J Am Med Inform Assoc. 2003; 10: 115-28. PubMed PMID: 12595401

High Alert Medications - Anticoagulants

Bibliography

  • Murray JM, Hellinger A, Dionne R, et al. Utility of a dedicated pediatric cardiac anticoagulaion program: the Boston Children's Hospital experience. Pediatr Cardiol. 2015 Apr;36(4):842-50. PubMed PMID: 25573076
  • Moore SJ, Blair EA, Steeb DR, et al. Impact of video technology on efficiency of pharmacist-provided anticoagulation counseling and patient comprehension. Ann Pharmacother. 2015 Jun;49(6):631-8. PubMed PMID: 25788517
  • Schillig J, Kaatz S, Hudson M, et al. Clinical and Safety impact of an inpatient pharmacist-directed anticoagulation service. J Hosp Med. 2011 Jul-Aug;6)6):322-8. PubMed PMID: 21834113
  • Nutescu EA, Wittkowsky AK, Witt DM, et al. Integrating electronic health records in the delivery of optimized anticoaguation therapy. Ann Pharmacother. 2015 Jan;49(1):125-6. PubMed PMID: 25524928
  • Fanikos J, Fiumara K, Baroletti S, et al. Impact of smart infusion technology on administration of anticoagulants (unfractionated Heparin, Argatroban, Leopirudin, and Bivalirudin). Am J Cardiol. 2007 Apr 1;99(7):1002-5. PubMed PMID: 17398201
  • Andreica I, Grissinger M. Oral Anticoagulants: A Review of Common Errors and Risk Reduction Strategies. Pa Patient Saf Advis. 2015 Jun;12(2):54-61.

Other Resources

High Alert Medications - Chemotherapy

Bibliography

  • Weingart SN, Toro J, Spencer J, et al. Medication errors involving oral chemotherapy. Cancer. 2010 May 15;116(10):2455-64. PubMed PMID: 20225328
  • Riechelmann RP, Tannock IF, Wang L, Saad ED, Taback NA, Krzyzanowska MK. Potential drug interactions and duplicate prescriptions among cancer patients. J Natl Cancer Inst. 2007 Apr 18;99(8):592-600. PubMed PMID: 17440160
  • Bartel SB. Safe practices and financial considerations in using oral chemotherapeutic agents. Am J Health Syst Pharm. 2007 May 1;64(9 Suppl 5):S8-S14. PubMed PMID: 17468158
  • Bonnabry P, Cingria L, Ackermann M, Sadeghipour F, Bigler L, Mach N. Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int J Qual Health Care. 2006 Feb;18(1):9-16. PubMed PMID: 16275659
  • Voeffray M, Pannatier A, Stupp R, Fucina N, Leyvraz S, Wasserfallen JB. Effet of computerization on the quality and safety of chemotherapy prescription. Qual Saf Health Care. 2006 Dec;15(6):418-21. PubMed PMID: 17142590
  • Schulmeister L. Ten simple strategies to prevent chemotherapy errors. Clin J Oncol Nurs. 2005 Apr;9(2):201-5. PubMed PMID: 15853163
  • Gandhi TK, Bartel SB, Shulman LN, et al. Medication safety in the ambulatory chemotherapy setting. Cancer. 2005 Dec 1;104(11):2477-83. PubMed PMID: 16245353
  • Aita M, Belvedere O, De Carlo E, et al. Chemotherapy prescribing errors: an obervational study on the role of information technology and computerized physian order entry systems. BMC Health Serv Res. 2013 Dec 17;13:522. PubMed PMID: 24344973
  • Bubalo J, Warden BA, Wiegel JJ, et al. Does applying technology throughout the medications use process improve patient safety with antineoplastics? J Oncol Pharm Pract. 2014 Dec;20(6):445-60. PubMed PMID: 24356802

Other Publications

  • ISMP International Medication Safety Self Assessment for Oncology. 2012.

High Alert Medications - Insulin

Bibliography

  • Cousins D, Rosario C, Scarpello J. Insulin, hospitals, and harm: a review of patient safety incidents reported to the National Patient Safety Agency. Clin Med. 2011 Feb;11(1);28-30. PubMed PMID: 21404780
  • Cobaugh DJ, Maynard G, Cooper L, et al. Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel. Am J Health Syst Pharm. 2013 Aug 15;70(16):1404-13. PubMed PMID: 23903479
  • Carson SL. Patient-supplied medication infusion devices in the emergency department: are you ready? J Emerg Nurs. 2012 May;38(3):267-9. PubMed PMID: 22425520
  • Cohen MR. Pharmacists' role in ensuring safe and effective hospital use of insulin. Am J Health Syst Pharm. 2010 Aug;67(16 Suppl 8):S17-21. PubMed PMID: 20689148
  • Hellman R. Patient safety and inpatient glycemic control: translating concepts into action. Endocr Pract. 2006 Jul-Aug;12 Suppl 3:49-55. PubMed PMID: 16905517
  • Cornish W. Safe and appropriate use of insulin and other antihyperlgycemic agents in hospital. Can J Diabetes. 2014 Apr;38(2):94-100. PubMed PMID: 24690504
  • Rousseau MP, Beauchesne MF, Naud AS, et al. An interprofessional qualitative study of barriers and potential solutions for the safe use of insulin in the hospital setting. Can J Diabetes. 2014 Apr;38(2):85-9. PubMed PMID: 24690502
  • Grissinger M, Gaunt MJ. Reducing harm in patients using insulin. Consult Pharm. 2014;29(5):290-302. PubMed PMID: 24849687
  • Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Intern Med. 2014 May;174(5):678-86. PubMed PMID: 24615164
  • Samaan KH, Dehlke M, Stover J. Addressing safety concerns about U-500 unsulin in a hospital setting. Am J Health Syst Pharm. 2011 Jan 1;68(1):63-8. PubMed PMID: 21164068
  • Lefkowitz M. Do different body colors and labels of insulin pens enhance a patient's ability to correctly identify pens for injecting long-acting versus short-acting insulins? J Diabetes Sci Technol. 2011 Jan1;5(1):136-49. PubMed PMID: 21303636
  • Lamont T, Cousins D, Hillson R, Bischler A, Terblanche M. Safer administration of insulin: summary of a safety report from the National Patient Safety Agency. BMJ. 2010 Oct 13;341:c5269. PubMed PMID: 20943723
  • Kelly JL. Ensuring optimal insulin utilization in the hospital setting: role of the pharmacist. Am J Health Syst Pharm. 2010 Aug;67(16 Suppl 8):S9-16. PubMed PMID: 20689152
  • Donihi AC, DiNardo MM, DeVita MA, Korytkowski MT. Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin. Qual Saf Health Care. 2006 Apr;15(2):89-91. PubMed PMID: 16585106
  • Schaefer MK, Kossover RA, Perz JF. Sharing insulin pens: Are you putting patients at risk? Diabetes Care. 2013 Nov;35(11):e188-9. PubMed PMID: 24159184
  • Gaunt MJ. The Current State of "Wrong Patient" Insulin Pen Injections. Pa Patient Saf Advis. 2015 Sep;12(3):110-5.

Other Resources

  • Institute for Safe Medication Practices. Considering insulin pens for routine hospital use? Consider this… ISMP Med Saf Alert Acute Care. 2008;13(9):1-3.
  • Institute for Safe Medication Practices. Ongoing concern about insulin pen reuse shows hospitals need to consider transitioning away from them. ISMP Med Saf Alert Acute Care. 2013;18(3):1-2.
  • Centers for Disease Control and Prevention. CDC clinical reminder: insulin pens must never be used for more than one person. 2012 Jan 05.
  • Institute for Safe Medication Practices. Hazard alert: reuse of insulin pen for multiple patients risks transmission of bloodborne disease. ISMP Med Saf Alert Acute Care. 2009;14(3):1-2.
  • Institute for Safe Medication Practices. A crack in our best armor: “wrong patient” insulin pen injections alarmingly frequent even with barcode scanning. ISMP Med Saf Alert Acute Care. 2014;19(21):1-5
  • Department of Veterans Affairs. Patient safety alert: multi-dose pen injectors. 2013 Jan 17.
  • Institute for Safe Medication Practices. A clinical reminder about the safe use of insulin vials. ISMP Med Saf Alert Acute Care. 2013 Feb 21;18(4);1-4.
  • One and Only Campaign. Insulin pen safety – one insulin pen, one person. 2012.

High Alert Medications - Opioids

Bibliography

  • Grissinger M. Results of the opioid knowledge assessment from the PA Hospital Engagement Network adverse drug event collaboration. Pa Patient Saf Advis. 2013 Mar;10(1):19-26.
  • Dy SM, Shore AD, Hicks RW, Morlock LL. Medication errors with opioids: results from a national reporting system. J Opioid Manag. 2007 Jul-Aug;3(4):189-94. PubMed PMID: 17957978
  • Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. 2012 Aug 8;49:1-5.
  • PA Patient Safety Authority. Adverse drug events with hydromorphone: how preventable are they? Pa Patient Saf Advis. 2010;7(3):69-75. 
  • Institute for Safe Medication Practices. HIGH ALERT Medication Feature: Reducing patient harm from opiates. ISMP Med Saf Alert Acute Care. 2007 Feb 22;12:1-3.
  • Vermaire D, Caruso MC, Lesko A, et al. Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital. BMJ Qual Saf. 2011 Oct;20(10):895-902. PubMed PMID: 21693465
  • Hicks RW, Sikirica V, Nelson W, Schein JR, Cousins DD. Medication errors involving patient-controlled analgesia. Am J Health Syst Pharm. 2008 Mar 1;65(5):429-40. PubMed PMID: 18281735
  • Kane-Gill SL, Rubin EC, Smithburger PL, Buckley MS, Dasta JF. The cost of opioid-related adverse drug events.J Pain Palliat Care Pharmacother. 2014 Sep;28(3):282-93. PubMed PMID: 25102043

Other Resources

  • Pennsylvania Hospital Engagement Network: Organization Assessment Of Safe Opioid Practices. Pennsylvania Patient Safety Authority. 2014.
  • Pennsylvania Patient Safety Authority, Pennsylvania Hospital Engagement Network, Pennsylvania Medical Society. Opioid Knowledge Self-Assessment. Pennsylvania Patient Safety Authority. 2013.
  • Cohen MR, Weber RJ, Moss J. Patient-Controlled Analgesia: Making It Safer for Patients – A continuing education program for pharmacists and nurses. Institute for Safe Medication Practices. 2006.
  • Vaida AJ, Urbanski B, Grissinger M, Mitchell JF. PCA Drug Libraries: Designing, Implementing, and Analyzing CQI Reports to Optimize Patient Safety – A continuing education program for pharmacists and nurses. Institute for Safe Medication Practices. 2007.
  • Opioid Adverse Drug Event Prevention Gap Analysis – Component of the Medication Safety Road Map. Minnesota Hospital Association. 2012.
  • Risk control strategies for reducing patient harm with HYDROmorphone. Institute for Safe Medication Practices.
  • FDA Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. U.S. Food and Drug Administration. Reference ID: 3805894. 2015.
  • White House Office of National Drug Control Policy.
  • Narcotic (Opioid) Medication Safety Initiative. Institute for Safe Medication Practices Canada. 2005.
  • Drug Safety and Availability: Opioid Medications. U.S. Food and Drug Administration. 2016.
  • Tool Kit: Patient Controlled Analgesia (PCA) Guidelines of Care for the Opioid Naïve Patient. San Diego Patient Safety Taskforce. 2008.

Incidence and Prevalence of Medication Errors and Adverse Drug Events

Bibliography

  • Garfield S, Reynolds M, Dermont L, Franklin BD. Measuring the severity of prescribing errors: a systematic review. Drug Saf. 2013 Dec;36(12):1151-7. PubMed PMID: 23955385
  • Keers RN, Williams SD, Cooke J, Ashcroft DM. Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence. Ann Pharmacother. 2013 Feb;47(2):237-56.  PubMed PMID: 23386063
  • Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009;32(5):379-89. PubMed PMID: 19419233
  • James KL, Barlow D, McArtney R, Hiom S, Roberts D, Whittlesea C. Incidence, type and causes of dispensing errors: a review of the literature. Int J Pharm Pract. 2009 Feb;17(1):9-30. PubMed PMID: 20218026
  • Krähenbühl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J, Krähenbühl S. Drug-related problems in hospitals: a review of the recent literature. Drug Saf. 2007;30(5):379-407. PubMed PMID: 17472418
  • Handler SM, Wright RM, Ruby CM, Hanlon JT. Epidemiology of medication-related adverse events in nursing homes. Am J Geriatr Pharmacother. 2006 Sep;4(3):264-72. PubMed PMID:  17062328

IV Medication Errors

Bibliography

  • Ohashi K, Dalleur O, Dykes PC, Bates DW. Benefits and risks of using smart pumps to reduce medication error rates: a systematic review. Drug Saf. 2014 Dec;37(12):1011-20. PubMed PMID: 25294653
  • Summa-Sorgini C, Fernandes V, Lubchansky S, et al. Errors Associated with IV Infusions in Critical Care. Can J Hosp Pharm. 2012 Jan;65(1):19-26. PubMed PMID: 22479108
  • Skledar SJ, Niccolai CS, Schilling D, Costello S, Mininni N, Ervin K, Urban A. Quality-improvement analytics for intravenous infusion pumps. Am J Health
    Syst Pharm. 2013 Apr 15;70(8):680-6. PubMed PMID: 23552046
  • Prusch AE, Suess TM, Paoletti RD, Olin ST, Watts SD. Integrating technology to improve medication administration. Am J Health Syst Pharm. 2011 May 1;68(9):835-42. PubMed PMID: 21515868
    Carayon P, Hundt AS, Wetterneck TB. Nurses' acceptance of Smart IV pump technology. Int J Med Inform. 2010 Jun;79(6):401-11. PubMed PMID: 20219423
  • Hertzel C, Sousa VD. The use of smart pumps for preventing medication errors. J InfusNurs. 2009 Sep-Oct;32(5):257-67. PubMed PMID: 20038875
  • Porat N, Bitan Y, Shefi D, Donchin Y, Rozenbaum H. Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety. Qual Saf Health Care. 2009 Dec;18(6):505-9. PubMed PMID: 19955466
  • Wollitz A. Grissinger M. Aligning the Lines: An Analysis of IV Line Errors. PA Patient Saf Advis. 2014 Mar;11(1):1-7.

Just Culture, Culture of Safety

Bibliography

  • Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: a systemic review. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):369-74. PubMed PMID: 23460092
  • Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. Strategies for improving patient safety culture in hospitals: a systematic review.BMJ Qual Saf. 2013 Jan;22(1):11-8. PubMed PMID: 22849965
  • Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? A review of the literature.  J Nurs Scholarsh. 2010 Jun;42(2):156-65. PubMed PMID: 20618600
  • Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture in health care. Health Care Manage Rev. 2009 Oct-Dec;34(4):312-22. PubMed PMID: 19858916
  • Mayer CM, Cronin D. Organizational accountability in a just culture. Urol Nurs. 2008 Dec; 28(6):427-30. PubMed PMID: 19241780
  • Scott-Cawiezell J, Vogelsmeier A, McKenney C, Rantz M, Hicks L, Zellmer D. Moving from a culture of blame to a culture of safety in the nursing home setting. Nurs Forum. 2006 Jul-Sep;41(3):133-40. PubMed PMID: 16879148
  • Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability. Health Serv Res. 2006 Aug;41 (4 Pt 2):1690-709. PubMed PMID: 16898986
  • Dennison RD. Creating an organizational culture for medication safety. Nurs Clin North Am. 2005 Mar;40(1):1-23. PubMed PMID: 15733943
  • Ruchlin HS, Dubbs NL, Callahan MA.The role of leadership in
    instilling a culture of safety: lessons from the literature. J Healthc Manag. 2004 Jan-Feb;49(1):47-58; discussion 58-9. PubMed PMID: 14768428
  • Firth-Cozens J. Cultures for improving patient safety through learning: the role of teamwork. Qual Health Care. 2001 Dec;10 Suppl 2:ii26-31. PubMed PMID: 11700376
  • Ferner RE. Medication errors that have led to manslaughter charges. BMJ. 2000 Nov 11;321(7270):1212-6. PubMed PMID: 11073516
  • Huang SW. The Omnibus Reconciliation Act of 1990: redefining pharmacists' legal responsibilities. Am J Law Med. 1998;24(4):417-42. PubMed PMID: 9876784
  • Pronovost PJ, Weast B, Holzmueller CG, et al. Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care. 2003; 12: 405-10. PubMed PMID: 14645754
  • Pronovost P, Sexton B. Assessing safety culture: guidelines and recommendations. Qual Saf Health Care. 2005; 14: 231-3. PubMed PMID: 16076784
  • Wachter RM, Pronovost PJ. Balancing "no blame" with accountability in patient safety. N Engl J Med. 2009; 361: 1401-6. PubMed PMID: 19797289

Leadership - Pharmacist

Bibliography

  • Ellinger LK, Trapskin PJ, Black R, Kotis D, Alexander E. Leadership and effective succession planning in health-system pharmacy departments. Hosp Pharm. 2014 Apr;49(4):369-75. PubMed PMID: 24958944
  • Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006 May 8;166(9):955-64. PubMed PMID: 16682568
  • Zellmer WA. Pharmacy vision and leadership: revisiting the fundamentals. Pharmacotherapy. 2008 Dec;28(12):1437-42. PubMed PMID: 19025424
  • Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service. J Hosp Med. 2011 Jul-Aug;6(6):322-8. PubMed PMID: 21834113
  • Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists' effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010 Oct;48(10):923-33. PubMed PMID: 20720510
  • Costello JL, Torowicz DL, Yeh TS. Effects of a pharmacist-led pediatrics medication safety team on medication-error reporting. Am J Health Syst Pharm. 2007 Jul 1;64(13):1422-6. PubMed PMID: 17592009
  • ASHP Guidelines on the Pharmacist's Role in the Development, Implementation, and Assessment of Critical Pathways. Am J Health Syst Pharm. 2004 May 1;61(9):939-45. PubMed PMID: 15156971

Look Alike Sound Alike Medications

Bibliography

  • Filik R, Purkdy K, Gale A, Gerrett D. Labeling of medicines and patient safety: evaluating methods of reducing drug name confusion. Hum Factors. 2006 Spring;48(1):39-47. PubMed PMID: 16696255
  • Hoffman JM, Proulx SM. Medication errors caused by confusion of drug names. Drug Saf. 2003;26(7)445-52. PubMed PMID: 12735783
  • Lambert BL, Lin SJ, Chang KY, Gandhi SK. Similarity as a risk factor in drug-name confusion errors: the look-alike (orthographic) and sound-alike (phonetic) model. Med Care. 1999 Dec;37(12):1214-25. PubMed PMID: 10599603
  • Lambert BL. Predicting look-alike and sound-alike medication errors. Am J Health Syst Pharm. 1997 May 15;54(10):1161-71. PubMed PMID: 9161623
  • Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J Clin Pharm. 2014 Apr;36(2):233-42. PubMed PMID: 24293334
  • Kovacic L, Chambers C. Look-alike, sound-alike drugs in oncology. J Oncol Pharm Pract. 2011 Jun;17(2):104-18. PubMed PMID: 20118216
  • Basco WT Jr, Ebeling M, Hulsey TC, Simpson K. Using pharmacy data to screen for look-alike, sound-alike substitution errors in pediatric prescriptions. Acad Pediatr. 2010 Jul-Aug;10(4):233-7. PubMed PMID: 20541485

Other Resources

Medication Errors

Books

  • Aspden P, Wolcott JA, Bootman JL, etal., eds. Preventing Medication Errors: Quality Chasm Series. Washington DC: National Academies Press; 2006. ISBN: 978-0-309-10147-9
  • Committee on the Assessment of the US Drug Safety System, Board on Population Health and Public Health Practice, Insitute of Medicine. The Future of Drug Safety: Promoting and Protecting the Health of the Public. Washington, DC; The National Academies Press; 2007. ISBN: 978-0-309-10304-6
  • Manasse Jr HR, Thompson KK, ed. Medication Safety: A Guide for Health Care Facilities. Bethesda, MD: American Society of Health-System Pharmacists; 2005. ISBN: 978-1-58528-089-6
  • Cohen MR, ed. Medication Errors, 2nd ed. Washington, DC: American Pharmacists Association; 2007. ISBN-13: 978-1582120928
  • Hepler CD, Segal R. Preventing Medication Errors and Improving Drug Therapy Outcomes: A Management Systems Approach. Boca Raton, FL: CRC Press; 2003. ISBN 9780849315763
  • Young C, Koopsen C, Farb D. Medication Errors Guidebook. Los Angeles, CA: UniversityOfHealthCare; 2005. ISBN-13: 978-1594912429

Bibliography

  • Kanse L, van der Schaaf TW, Vrijland ND, van Mierlo H. Error recovery in a hospital pharmacy. Ergonomics. 2006 Apr 15-May 15;49(5-6):503-16. PubMed PMID: 16717007
  • Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. QualSaf Health Care. 2006 Apr;15(2):122-6. PubMed PMID: 16585113
  • Nuckols TK, Smith-Spangler C, Morton SC, et al. The effectivess of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Syst Rev. 2014; Jun4;3:56. PubMed PMID: 24894078
  • MacKay M, Anderson C, Boehme S, Cash J, Zobell J. Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding. Nutr Clin Pract. 2016 Apr;31(2):195-206. PubMed ID: 26214511
  • South DA, Skelley JW, Dang M, Woolley T. Near-miss transcription errors: a comparison of reporting rates between a novel error-reporting mechanism and a current formal reporting system. Hosp Pharm. 2015 Feb;50(2):118-24. PubMed PMID: 25717207
  • Cochran GL, Haynatzki G. Comparison of medication safety effectivenss among nine critical access hospitals. Am J Health Syst Pharm. 2013 Dec 15;70(24):2218-24. PubMed PMID: 24296844
  • Latif A, Rawat N, Pustavoitau A, Pronovost PJ, Pham JC. National study on the distribution, cuases, and consequences of volunarily reported medication errors between the ICU and non-ICU settins. Crit Care Med. 2013 Feb;41(2):389-98. PubMed PMID: 23263619
  • Massachusetts Coalition for the Prevention of Medical Errors. When Things Go Wrong: Responding to Adverse Events. 2006.
  • Bakhsh HT, Perona SJ, Shields WA, Salek S, Sanders AB, Patanwala AE. Medication errors in psychiatric patients boarded in the emergency department. Int J Risk Saf Med. 2014;26(4):191-4. PubMed PMID: 25420761
  • Grissinger M, Alghamdi D. Omission of High-Alert Medications: A Hidden Danger. Pa Patient Saf Advis. 2014 Dec;11(4):149-55.

Medication Reconciliation and Transitions of Care

Bibliography

  • Sponsler KC, Neal EB, Kripalani S. Improving medication safety during hospital-based transitions of care. Cleve Clin J Med. 2015; 82(6):351-60. PubMed PMID: 26086494
  • Sanchez SH, Sethi SS, Santos SL, Boockvar K. Implementing medication reconciliation from the planner’s perspective: a qualitative study. BMC Health Serv Res. 2014; 14:290. PubMed PMID: 24996538
  • Lehnbom EC, Stewart MJ, Manias E, Westbrook JI. Impact of medication reconciliation and review on clinical outcomes. Ann Pharmac other. 2014; 48(10): 1298-312. PubMed PMID: 25048794
  • Henneman EA, Tessier EG, Nathanson BH, Plotkin K. An evaluation of a collaborative, safety-focused, nurse-pharmacist intervention for improving the accuracy of the medication history. J Patient Saf. 2014; 10(2):88-94. PubMed PMID: 24080716
  • Smith KJ, Handler SM, Kapoor WN, Martich GD, Reddy VK, Clark S. Automated Communication Tools and Computer-Based Medication Reconcilliation to Decrease Hospital Discharge Medication Errors. Am J Med Qual. 2015;pii: 1062860615574327. [Epub ahead of print] PubMed PMID: 25753453
  • Gao T, Gaunt MJ. Breakdowns in the Medication Reconciliation Process. Pa Patient Saf Advis. 2013 Dec;10(4):125-36.

Medication Use Process

Books

  • Kirschling TE, ed. The Handbook on Storing and Securing Medications, 2nd ed. Chicago, IL: Joint Commission Resources; 2009. ISBN: 978-1-59940-302-1
  • McNeil MJ, ed. ASHP's Safety and Quality Pearls. Bethesda, MD: American Society of Health-System Pharmacists; 2008. ISBN: 978-1-58528-197-8
  • Saine DR, ed. ASHP's Safety and Quality Pears 2. Bethesda, MD: American Society of Health-System harmacists; 2009 ISBN: 978-1-58528-217-3
  • Workman ML, LaCharity LA, Kruchko SL. Understanding Pharmacology: Essentials for Medication Safety. St. Louis, MO; Saunders; 2010. ISBN: 978-1-41602-917-5
  • Osheroff J. Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-Step Guide. Chicago, IL: Healthcare Information and Management Systems Society; 2009. ISBN: 978-0-98006-973-0
  • Tully MP, Franklin BD. Safety in Medication Use. Boca Raton, FL: CRC Press. 2016. ISBN: 9-781-48222-700-0

Bibliography

  • Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Systematic review of medication safety assessment methods. Am J Health Syst Pharm. 2011 Feb 1;68(3):227-40. PubMed PMID: 21258028
  • Skibinski KA, White BA, Lin LI, Dong Y, Wu W. Effects of technological interventions on the safety of a medication-use process. Am J Health Syst Pharm. 2007 Jan 1;64(1):90-6. PubMed PMID: 17189586
  • Vermuelen LC, Rough SS, Thielke TS, et al. Strategic approach for improving the medication-use process in health systems: the high-performance pharmacy practice framework. Am J Health Syst Pharm. 2007 Aug 15;64(16):1699-710. PubMed PMID: 17687058
  • Bubalo J, Warden BA, Wiegel JJ, et al. Does applying technology throughout the medications use process improve patient safety with antineoplastics? J Oncol Pharm Pract. 2014 Dec;20(6):445-60. PubMed PMID: 24356802

Medication Use Process – Administration Errors

Bibliography

  • Keers RN, Williams SD, Cooke J, Walsh T, Ashcroft DM. Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review. Drug Saf. 2014 May;37(5):317-32. PubMed PMID: 24760475
  • Keers RN, Williams SK, Cooke J, Ashcroft DM. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013 Nov;36(11):1045-67. PubMed PMID: 23975331
  • Anthony K, Wiencek C. Bauer C, Daly B, Anthony MK. No interruptions please, impact of a No Interruption Zone on medication safety in intensive care units. Crit Care Nurse. 2010 Jun;30(3):21-9. PubMed PMID 20067939
  • Westbrook JI, Wookds A, Rob MI Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010 Apr 26;170(8):683-90. PubMed PMID: 20421552
  • Berdot S, Sabatier B, Gillaizeau F, Caruba T, Prognon P, Durieux P. Evaluation of drug administration errors in a teaching  hospital. BMC Health Serv Res. 2012 Mar 12;12:60. PubMed PMID: 22409837

Medication Use Process – Dispensing Errors

Bibliography

  • James KL, Barlow D, McArtney R, Hiom S, Roberts D, Whittlesea C. Incidence, type and causes of dispensing errors: a review of the literature. Int J Pharm Pract. 2009 Feb;17(1):9-30. PubMed PMID: 20218026
  • Poon EG, Cina JL, Churchill W, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med. 2006 Sep 19;145(6):426-34. PubMed PMID: 16983130
  • Cina JL, Gandhi TK, Churchill W, et al. How many hospital pharmacy medication dispensing errors go undetected? Jt Comm J Qual Patient Saf. 2006 Feb;32(2):73-80. PubMed PMID: 16568920
  • Paparella S. Automated dispensing systems not error free. J Emerg Nurs. 2006 Feb;32(1):71-4. PubMed PMID: 16439294
  • Rochais E, Atkinson S, Guilbeault M, Bussieres JF. Nursing perception on the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center. J Pharm Pract. 2014 Apr;27(2):150-7. PubMed PMID: 24128784
  • Rochais E, Atkinson S, Guilbeault M, Bussieres JF. Nursing perception on the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center. J Pharm Pract. 2014 Apr;27(2):150-7. PubMed PMID: 24128784
  • Cohen MR, Smetzer JL, Westphal JE, Comden SC, Horn DM. Risk models to improve safety of dispensing high-alert medications in community pharmacies. J Am Pharm Assoc (2003). 2012 Sep-Oct;52(5):584-602. PubMed PMID: 23023839
  • Mandrack M, Cohen MR, Featherling J, Gellner L, Judd K, Kienle PC, Vanderveen T. Nursing best practices using automated dispensing cabinets: nurses' key role in improving medication safety. Medsurg Nurs. 2012 May-Jun;21(3):134-9, 144. PubMed PMID: 22866432

Medication Use Process – Prescribing Errors

Bibliography

  • Barber N. Electronic prescribing - safer, fast, better? J Health Serv Res Policy. 2010 Jan;15 Suppl 1:64-7. PubMed PMID: 20075133
    Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009;32(5):379-89. PubMed PMID: 19419233
  • Bobb A, Gleason K, Husch M, Feinglass J, Yarnold PR, Noskin GA. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med. 2004 Apr 12;164(7):785-92. PubMed PMID: 15078649
  • Rupp MT, Warholak TL. Evaluation of e-prescribing in chain community pharmacy: best-practice recommendations. J Am Pharm Assoc (2003). 2008 May-Jun;48(3):364-70. PubMed PMID: 18595821
  • Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc. 2008 Oct;56(10):1946-52. PubMed PMID: 18771457

Pediatric Medication Safety

Bibliography

  • Li Q, Kirkendall ES, Hall ES,et al. Automated detection of medication administration errors in neonatal intensive care. J Biomed Inform. J Biomed Inform. 2015 Jul 17. pii: S1532-0464(15)00152-5. PubMed PMID: 26190267
  • de Bie S, Ferrajolo C, Straus SM, et al. Pediatric Drug Safety Surveillance in FDA-AERS: A Description of Adverse Events from GRiP Project. PLoS ONE. 2015 Jun 19;10(6):e0130399. PubMed PMID: 26090678
  • Stultz JS, Nahata MC. Preventability of Voluntarily Reported or Trigger Tool-Identified Medication Errors in a Pediatric Institution by Information Technology: A Retrospective Cohort Study. Drug Saf. 2015 Jul;38(7):661-70. PubMed PMID 26013909
  • Smith MD, Spiller HA, Casavant MJ, Chounthirath T, Brophy TJ, Xiang H. Out-of-Hospital Medication Errors Among Young Children in the United States, 2002–2012. Pediatrics. 2014 Nov;134(5):867-876. PubMed PMID: 25332497
  • Rinke ML, Bundy DG, Velasquez CA, et al. Interventions to Reduce Pediatric Medication Errors: A Systematic Review. Pediatrics. 2014 Aug;134(2):338-360. PubMed PMID: 25022737
  • Walsh KE, Roblin DW, Weingart SN, et al. Medication Errors in the Home: A Multisite Study of Children With Cancer. Pediatrics. 2013 May;131(5):e1405-1414. PubMed PMID: 23629608
  • Yin HS, Dreyer BP, Ugboaja DC, et al. Unit of Measurement Used and Parent Medication Dosing Errors. Pediatrics. 2014 Aug;134(2):e354-61. PubMed PMID: 25022742
  • Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001 Apr 25;285(16):2114-20. PubMed PMID: 11311101
  • Dabliz R, Levine S. Medication safety in neonates. Am J Perinatol. 2012;29:49-56. PubMed PMID: 21861251
  • Stucky ER, Amaerican Academy of Pediatrics Committee on Drugs, American Academy of Pedatrics Committee on Hospital Care. Prevention of medication errors in pediatric inpatient setting. Pediatrics. 2003 Aug;112(2):431-6. PubMed PMID: 12897304
  • Levine SR, Cohen MR, Blanchard NR, et al. Guidelines for preventing medication errors in pediatrics. J Pediatr Pharmacol Ther. 2011;6:426-42.
  • Takata GS, Mason W, Taketomo C, Logsdon T, Sharek PJ. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics. 2008;121(4):927-35. PubMed PMID: 18381521
  • Grissinger M. Medication Errors Affecting Pediatric Patients: Unique Challenges for this Special Population. Pa Patient Saf Advis. 2015 Sep;12(3):96-102.

Patient Safety

Books

  • Aspden P, Corrigan JM, Wolcott J. Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academies Press; 2004. ISBN: 978-0-309-09077-3
  • Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. ISBN: 978-0-309-07280-9
  • Cousins DD, ed. Advancing Patient Safety in U.S. Hospitals: Basic Strategies for Success. Rockville, MD: US Pharmacopeia; 2004. ISBN: 978-1-889-78833-3
  • Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Patient Safety in Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 978-0-781-77727-8
  • Dekker S. Patient Safety: A Human Factors Approach. New York, NY: CRC Press; 2011. ISBN: 978-1-439-85225-5
  • Farley DO, Ridgely MS, Mendel P, et al. Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System. Santa Monica, CA: RAND Corporation; 2009. ISBN: 978-0-8330-4902-5
  • Krug SE, ed. Pediatric Patient Safety in the Emergency Department. Oak Brook, IL: Joint Commission Resources and the American Academy of Pediatrics; 2010. ISBN: 978-1-59940-212-3
  • Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999. ISBN: 978-0-309-26174-6
  • Wachter R. Understanding Patient Safety, 2nd ed. New York: McGraw Hill Medical; 2012. ISBN: 978-0-071-76578-7
  • Nance JJ. Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Bozeman, MT: Second River Healthcare; 2008. ISBN: 978-0-974-38606-5
  • Gawande A. The Checklist Manifesto: How to Get Things Right. New York: Metropolitan Books; 2009. ISBN: 978-0-312-43000-9
  • Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. New York: Penguin Group; 2010.ISBN: 978-0-452-29686-2

Bibliography

  • Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013; 158: 365-8. PubMed PMID: 23460091
  • Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand. 2009; 53: 143-51.  PubMed PMID: 19032571
  • Runciman W, Hibbert P, Thomson R, Van Der Schaaf T, Sherman H, Lewalle P. Towards an International Classification for Patient Safety: key concepts and terms. Int J Qual Health Care. 2009; 21: 18-26. PubMed PMID: 19147597
  • Wachter RM. Patient Safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood). 2010; 29: 165-73.  PubMed PMID: 19952010
  • Leape LL, Berwick DM. Five years after To Err is Human: what have we learned? JAMA. 2005; 18: 2384-90. PubMed PMID: 15900009
  • Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA. 2002; 288: 501-7. PubMed PMID: 12132984
  • Leape L, Berwick D, Clancy D, et al. Transforming healthcare:  a safety imperative. Qual Saf  Health Care. 2009; 18: 424-8.  PubMed PMID: 19955451
  • Hales BM, Pronovost PJ. The checklist - a tool for error management and performance improvement. J Crit Care. 2006; 21: 231-5. PubMed PMID: 16990087
  • Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Creating high reliability in health care organizations. Health Serv Res. 2006; 41: 1599-617. PubMed PMID: 16898981
  • Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Reality check for checklists. Lancet. 2009; 374: 444-5. PubMed PMID: 19681190
  • Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: an elusive target. JAMA. 2006; 296: 696-9. PubMed PMID: 16896113
  • Shekelle PG, Pronovost PJ, Wachter RM, et al. Advancing the science of patient safety. Ann Intern Med. 2011; 154: 693-6. PubMed PMID: 21576538
  • Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The "To Err is Human" report and the patient safety literature. Qual Saf Health Care.  2006; 15: 174-8. PubMed PMID: 16751466
  • Shojania KG, Duncan BW, McDonald KM, Wachter RM. Safe by sound: patient safety meets evidence-based medicine. JAMA. 2002; 288: 508-13. PubMed PMID: 12132985
  • Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA. 2006; 295: 324-7. PubMed PMID: 16418469
  • Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007; 297: 831-41. PubMed PMID: 17327525
  • Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med. 2002; 347: 1249-55. PubMed PMID: 12393823
  • Cook R, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000; 320: 791-4. PubMed PMID: 10720370
  • Colla JB, Bracken AC, Kinney LM, Weeks WB. Measuring patient safety climate: a review of surveys. Qual Saf Health Care. 2005; 14: 364-6. PubMed PMID: 16195571
  • Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005; 142: 756-64. PubMed PMID: 15867408
  • Romano PS, Geppert JJ, Davies S, Miller MR, Elixhauser A, McDonald KM. A national profile of patient safety in U.S. hospitals. Health Aff (Millwood). 2003; 22: 154-66. PubMed PMID: 12674418
  • Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care. 2002; 11: 76-80. PubMed PMID: 12078376

Pharmacists’ Role in Medication Safety

Books

  • Larson CM, Saine D. Medication Safety Officer’s Handbook. Bethesda, MD: American Society of Health-System Pharmacists. 2013. ISBN: 978-1-58528-210-4

Bibliography

  • Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists' effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010; 48: 923-33. PubMed PMID: 20720510
  • Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006; 166: 565-71. PubMed PMID: 16534045
  • Horn E, Jacobi J. The critical care clinical pharmacist: evolution of an essential team member. Crit Care Med. 2006; 34: S46-51. PubMed PMID: 16477202
  • Kowiatek JG, Weber RJ, Skledar S, Sirio C. Medication safety manager in an academic medical center. Am J Health Syst Pharm. 2004; 61: 58-64. PubMed PMID: 14725123
  • Rollason V, Vogt N. Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist. Drugs Aging. 2003; 20: 817-32. PubMed PMID: 12964888
  • Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999; 282: 267-70. PubMed PMID: 10422996
  • Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006; 166: 955-64. PubMed PMID: 16682568
  • Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med. 2003; 163: 2014-8. PubMed PMID: 14504113
  • Costello JL, Torowicz DL, Yeh TS. Effects of a pharmacist-led pediatrics medication safety team on medication-error reporting. Am J Health Syst Pharm. 2007; 64: 1422-6. PubMed PMID: 17592009
  • Gattis WA, Hasselblad V, Whellan DJ, O'Connor CM. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team: results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study. Arch Intern Med. 1999; 159: 1939-45. PubMed PMID: 10493325
  • Kaushal R, Bates DW, Abramson EL, Soukup JR, Goldmann DA. Unit-based clinical pharmacists' prevention of serious medication errors in pediatric inpatients. Am J Health Syst Pharm. 2008; 65: 1254-60. PubMed PMID: 18574016
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Root Cause Analysis

Bibliography

  • Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008 Feb 13;299(6):685-7. PubMed PMID: 18270357
  • Smetzer J, Baker C, Byrne FD, Cohen MR. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Jt Comm J Qual Patient Saf. 2010; 36:152-63. PubMed PMID: 20402372
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Other Publications

  • RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. National Patient Safety Foundation. 2015.
  • Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. ISMP.
  • Root Cause Analysis. VA National Center for Patient Safety. U.S. Department of Veterans Affairs.
  • Root Cause Analysis. Patient Safety Primers. Agency for Healthcare Research and Quality. Last updated: August 2014.
  • Patient Safety Systems Chapter, Sentinel Event Policy and RCA2. The Joint Commission.

Second Victim

Bibliography

  • Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider "second victim" after adverse patient events. Qual Saf Health Care. 2009;18: 325-30.  PubMed PMID: 19812092
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  • Burlison JD, Scott SD, Browne EK, Thompson SG, Hoffman JM. The Second Victim Experience and Support Tool: Validation of an Organizational Resource for Assessing Second Victim Effects and the Quality of Support Resources. J Patient Saf. 2014 Aug 26. [Epub ahead of print]. PubMed PMID: 25162208
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  • Mira JJ, Carrilo I, Lorenzo S, et al. The aftermath of adverse events in Spanish primary care and hospital health professionals. BMC Health Serv Res. 2015; 15: 151. PubMed PMID: 25886369
  • Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010; 36: 233-240. PubMed PMID: 20480757
  • Seys D, Wu AW, Van Gerven E, et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2013; 36: 135-162. PubMed PMID: 22976126
  • Pratt S, Kenney L, Scott SD, Wu AW. How to develop a second victim support program: a toolkit for health care organizations. Jt Comm J Qual Patient Saf. 2012; 38: 235-40, 193. PubMed PMID: 22649864
  • Institute for Safe Medication Practices. Too many abandon the "second victims" of medical errors.ISMP Med Saf Alert Acute Care. 2011;16(14):1-3.
  • Conway J, Federico F, Stewart K, Campbell MJ. Respectful management of serious clinical adverse events. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2010.

Sterile Compounding Safety

Bibliography

  • Lanze A, Rudner S. Certification of sterile equipment and facilities: what pharmacists need to know. Int J Pharm Compd. 2014 Sep-Oct;18(5):397-9. PubMed PMID: 25577889
  • Allen LV Jr. Basics of compounding sterile preparations: nomenclature and considerations. Int J Pharm Compd. 2014 Jul-Aug;18(4):313-7. PubMed PMID: 25474860
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  • Hicks RW.Understanding medication compounding issues. AORN J. 2014 Apr;99(4):466-76; quiz 477-9. PubMed PMID: 24674793
  • Rich DS, Fricker MP Jr, Cohen MR, Levine SR. Guidelines for the Safe Preparation of Sterile Compounds: Results of the ISMP Sterile Preparation Compounding Safety Summit of October 2011. Hosp Pharm. 2013 Apr;48(4):282-94. PubMed PMID: 24421477
  • Gudeman J, Jozwiakowski M, Chollet J, Randell M. Potential risks of pharmacy compounding. Drugs R D. 2013 Mar;13(1):1-8. PubMed PMID: 23526368
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  • Rinehart JR, Chan D, Cunningham M, et al. ASHP guidelines on outsourcing sterile compounding services. Am J Health Syst Pharm. 2010 May 1;67(9):757-65. PubMed PMID: 20410553
  • Cooper JF, Latta KS, Smith D. Automated endotoxin testing program for high-risk-level compounded sterile preparations at an institutional compounding pharmacy. Am J Health Syst Pharm. 2010 Feb 15;67(4):280-6. PubMed PMID: 20133532
  • Mullarkey T.Pharmacy compounding of high-risk level products and patient safety. Am J Health Syst Pharm. 2009 Sep 1;66(17  Suppl 5):S4-13. PubMed PMID: 19710449

Other

  • ASHP Guidelines on Outsourcing Sterile Compounding Services. Am J Health-Syst Pharm. 2015;72:1662-75. PubMed PMID: 26386108

Trigger Drugs

Bibliography

  • Call RJ, Burlison JD, Robertson JJ,  et al. Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population. J Pediatr. 2014; 165: 447-52. PubMed PMID: 24768254
  • Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics. 2006; 118: 1332-40. PubMed PMID: 17015521
  • Szekendi MK, Sullivan C, Bobb A, et al. Active surveillance using electronic triggers to detect adverse events in hospitalized patients. Qual Saf Health Care. 2006; 15: 184-90. PubMed PMID: 16751468
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  • Classen DC, Resar R, Griffin F, et al. Global trigger tool shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff. 2011; 30: 581-9. PubMed PMID: 21471476
  • Resar RK, Rozich JD, Classen D. Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care. 2003; 12: Suppl 2:ii39-45. PubMed PMID: 14645894
  • 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. PubMed PMID: 12792009
  • Stockwell DC, Bisarya H, Classen DC, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015; 135: 1036-42. PubMed PMID: 25986015
  • Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc. 1998; 5: 305-14. PubMed PMID: 9609500
  • Kilbridge PM, Campbell UC, Cozart HB, Mojarrad MG. Automated surveillance for adverse drug events at a community hospital and an academic medical center. J Am Med Inform Assoc. 2006; 13: 372-7. PubMed PMID: 16622159
  • Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009.
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