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Medication Use Safety Resources

Online Tools and Resources


Recommended Reading

Book and Bibliography of Patient Safety Articles

Adverse Drug Reactions and Adverse Drug Events

BOOKS
Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events. Second edition. Cambridge, MA: Institute for Healthcare Improvement; 2011.

Bibliography

  1. Kanaan AO, Donovan JL, Duchin NP, Field TS, Tjia J, Cutrona SL, Gagne SJ, Garber L, Preusse P, Harrold LR, Gurwitz JH. 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. doi: 10.1111/jgs.12504. Epub 2013 Oct 1. PubMed PMID: 24116689
  2. Cano FG, Rozenfeld S. Adverse drug events in hospitals: a systematic review. Cad SaudePublica. 2009;25 Suppl 3:S360-72. Review. PubMed PMID: 20027385.
  3. 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.
  4. 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. Epub 2007 Jul 31. Review. PubMed PMID: 17666582.
  5. Cresswell KM, Fernando B, McKinstry B, Sheikh A. Adverse drug events in the elderly. Br Med Bull. 2007;83:259-74. Epub 2007 Jun 18. Review. PubMed PMID: 17580312.
  6. 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. Review. PubMed PMID: 17610221.
  7. Routledge PA, O'Mahony MS, Woodhouse KW. Adverse drug reactions in elderly patients. Br J Clin Pharmacol. 2004 Feb;57(2):121-6. Review. PubMed PMID: 14748810; PubMed Central PMCID: PMC1884428.

Automation and Technology

BOOKS
Phelps, PK, ed. Smart Infusion Pumps. Bethesda, MD: American Society of Health-
System Pharmacists; 2011.
 

Bibliography of Key Patient Safety Articles

  1. Leung AA, Denham CR, Gandhi TK, Bane A, Churchill WW, Bates DW, Poon EG. A Safe Practice Standard for Barcode Technology. J Patient Saf. 2014 Mar 10. [Epub ahead of print]PubMed PMID: 24618650
  2. 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. PMID:22357106
  3. Forni A, Chu HT, Fanikos J. Technology utilization to prevent medication errors. Curr Drug Saf. 2010 Jan;5(1):13-8. PubMed PMID: 20210714.
  4. Schnipper JL, Hamann C, Ndumele CD, Liang CL, Carty MG, Karson AS, Bhan I, Coley CM, Poon E, Turchin A, Labonville SA, Diedrichsen EK, Lipsitz S, Broverman CA, McCarthy P, Gandhi TK. 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. doi: 10.1001/archinternmed.2009.51. PubMed PMID: 19398689.
  5. Koppel R1, 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. PMID:18436903
  6. 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.
  7. 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.
  8. Rothschild JM, Keohane CA, Cook EF, Orav EJ, Burdick E, Thompson S, Hayes J, Bates DW. 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.
  9. 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. Review. PubMed PMID: 12595401; PubMed Central PMCID: PMC150365

Automation and Technology – Electronic Medical Records, COPE, and Alerts

Bibliography of Key Patient Safety Articles

  1. Buntin MB1, 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. doi: 10.1377/hlthaff.2011.0178. PMID:21383365
  2. Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008 Sep-Oct;15(5):585-600. doi: 10.1197/jamia.M2667. Epub 2008 Jun 25. Review. PubMed PMID: 18579832; PubMed Central PMCID: PMC2528040.
  3. Wolfstadt JI, Gurwitz JH, Field TS, Lee M, Kalkar S, Wu W, Rochon PA. The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review. J Gen Intern Med. 2008 Apr;23(4):451-8. doi: 10.1007/s11606-008-0504-5. Review. PubMed PMID: 18373144; PubMed Central PMCID: PMC2359507.
  4. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005 Mar 9;293(10):1197-203. PubMed PMID: 15755942.
  5. 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. Epub 2005 Dec 15. PubMed PMID: 16357358; PubMed Central PMCID: PMC1447540.
  6. 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. Review. PubMed PMID: 12824090.
  7. 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.

Disclosure

Bibliography of Key Patient Safety Articles

  1. 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. doi: 10.1093/intqhc/mzq042. Epub 2010 Aug 13. Review.PMID:20709703.
  2. 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. doi: 10.1378/chest.09-0030.PMID: 19736193.
  3. Boyle D, O'Connell D, Platt FW, Albert RK. Crit Care Med. Disclosing errors and adverse events in the intensive care unit. 2006 May;34(5):1532-7. PMID:16540948. Acknowledging our mistakes.Luce JM. Crit Care Med. 2006 May; 34(5):1575-6.
  4. 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. doi: 10.1093/intqhc/mzq042. Epub 2010 Aug 13. Review.PMID:20709703.

Economic Impact

Bibliography of Key Patient Safety Articles

  1. Hug BL, Keohane C, Seger DL, Yoon C, Bates DW. The costs of adverse drug events in community hospitals. JtComm J Qual Patient Saf. 2012 Mar;38(3):120-6. PubMed PMID: 22435229.
  2. 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. doi: 10.1177/1062860608327610. PubMed PMID: 19139464.
  3. 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
  4. 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. Review. PubMed PMID: 12856901.
  5. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients.  JAMA. 1997;277:307-311.

Errors in Medicine and Human Error

BOOKS

Dekker S. The Field Guide to Understanding Human Error. Burlington, VT: Ashgate; 2006.

Kohn LT, Corrigan JM, Donaldson MS. eds. To Err is Human, Building a Safer HealthSystem. Washington, DC: National Academy Press; 2000.

Reason J, The Human Contribution. Burlington, VT: Ashgate Publishing Company; 2008.

Reason J, ed. Human Error. Cambridge: Cambridge University Press; 1990.

Senders JW, Moray NP.  Human Error: Cause, Prediction, and Reduction. Boca Raton, FL: CRC Press; 1991.

Woods D, Dekker S, Cook R, Johannesen L. Behind Human Error. Burlington, VT: Ashgate Publishing Company; 2010.

Bibliography of Key Patient Safety Articles

  1. 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.
  2. 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. QualSaf Health Care. 2006 Feb;15(1):23-31. Review. PubMed PMID: 16456206; PubMed Central PMCID: PMC2563996.
  3. 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. Review. PubMed PMID: 15579349.
  4. 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. Review. PubMed PMID: 16129874; PubMed Central PMCID: PMC1188190.

Incidence and Prevalence of Medication Errors and Adverse Drug Events

BOOKS

Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. New York: Rugged Land; 2005.

Bibliography of Key Patient Safety Articles

  1. 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. doi: 10.2165/00002018-200932050-00002. Review. PubMed PMID: 19419233.
  2. 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. Review. PubMed PMID: 20218026.
  3. 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.
  4. Handler SM, Wright RM, Ruby CM, Hanlon JT. Epidemiology of medication-related adverse events in nursing homes. Am J GeriatrPharmacother. 2006 Sep;4(3):264-72. Review. PubMed PMID: 17062328.

IV Medication Errors

BOOKS

Recommendations for Safe Use of Insulin in Hospitals. Bethesda, MD: American Society of Health-System Pharmacists; 2006.

Bibliography of Key Patient Safety Articles

  1. 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. doi: 10.2146/ajhp100211. PubMed PMID: 21515868.
  2. Carayon P, Hundt AS, Wetterneck TB. Nurses' acceptance of Smart IV pump technology. Int J Med Inform. 2010 Jun;79(6):401-11. doi: 10.1016/j.ijmedinf.2010.02.001. Epub 2010 Mar 12. PubMed PMID: 20219423; PubMed Central PMCID: PMC2862878
  3. Hertzel C, Sousa VD. The use of smart pumps for preventing medication errors. J InfusNurs. 2009 Sep-Oct;32(5):257-67. doi: 10.1097/NAN.0b013e3181b40e2e. PubMed PMID: 20038875.
  4. 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.QualSaf Health Care. 2009 Dec;18(6):505-9. doi: 10.1136/qshc.2007.025726. PubMed PMID: 19955466.

Just Culture, Culture of Safety

BOOKS

Antonsen S. Safety Culture: Theory, Method and Improvement. Burlington, VT: Ashgate; 2009.

Dekker S. Just Culture: Balancing Safety and Accountability, Second Edition. Aldershot, England: Ashgate Publishing Limited; 2012.

Marx D. Patient Safety and the "Just Culture": A Primer for Health Care Executives. New York, NY: Columbia University; 2001.

Marx D. Whack-a-Mole: The Price We Pay For Expecting Perfection. Plano, TX: By Your Side Studios; 2009.

Patankar MS, Brown JP, Sabin EJ, Bigda-Peyton TG. Safety Culture: Building and Sustaining a Cultural Change in Aviation and Healthcare. Burlington, VT: Ashgate; 2012.

Bibliography of Key Patient Safety Articles

  1. 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. doi: 10.1136/bmjqs-2011-000582. Epub 2012 Jul 31. Review.  PMID: 22849965.
  2. 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. doi: 10.1111/j.1547-5069.2009.01330.x. Review.  PMID: 20618600.
  3. 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. doi: 10.1097/HMR.0b013e3181a3b709. Review.PMID:19858916.
  4. Mayer CM, Cronin D. Organizational accountability in a just culture. Urol Nurs. 2008 Dec; 28(6):427-30. Review. PMID: 19241780.
  5. 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.
  6.  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. PMID: 16898986.
  7. Dennison RD. Creating an organizational culture for medication safety. Nurs Clin North Am. 2005 Mar;40(1):1-23. Review. PMID:15733943.
  8. 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. Review.PMID:14768428.
  9. Firth-Cozens J. Cultures for improving patient safety through learning: the role of teamwork. J Qual Health Care. 2001 Dec;10 Suppl 2:ii26-31PMID:11700376.
  10. Ferner RE. Medication errors that have led to manslaughter charges. BMJ. 2000 Nov 11;321(7270):1212-6. Review. PubMed PMID: 11073516; PubMed Central PMCID: PMC1118964.
  11. Huang SW. The Omnibus Reconciliation Act of 1990: redefining pharmacists' legal responsibilities. Am J Law Med. 1998;24(4):417-42. Review. PubMed PMID: 9876784.

Leadership-Pharmacist

BOOKS

Krause TR, Hidley J. Taking the Lead in Patient Safety: How Healthcare Leaders Influence Behavior and Create Culture. Hoboken, NJ: Wiley; 2008.

Mager R, Analyzing Performance Problems. Atlanta, GA: The Center for Effective Performance; 3rd ediction, 1997

Bibliography of Key Patient Safety Articles

  1. 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. doi: 10.1002/jhm.910. PubMed PMID: 21834113.
  2. Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, Graff Zivin J, Abraham I, Palmer J, Martin JR, Kramer SS, Wunz T. US pharmacists' effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010 Oct;48(10):923-33. doi: 10.1097/MLR.0b013e3181e57962. Review. PubMed PMID: 20720510.
  3. 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.
  4. 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

Bibliography of Key Patient Safety Articles

  1. Filik R, Purdy 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.
  2. Hoffman JM, Proulx SM. Medication errors caused by confusion of drug names. Drug Saf. 2003;26(7):445-52. Review. PubMed PMID: 12735783.
  3. 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.
  4. 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.

Medication Errors

BOOKS

Aspden P, Wolcott JA, Bootman JL et al., eds. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2006.

Committee on the Assessment of the US Drug Safety System, Board on Population Health and Public Health Practice, Institute of Medicine. The Future of Drug Safety: Promoting and Protecting the Health of the Public. Washington, DC; The National Academies Press; 2007.

Manasse Jr HR, Thompson KK, ed. Medication Safety: A Guide for Health Care Facilities. Bethesda, MD: American Society of Health-System Pharmacists; 2005.

Bibliography of Key PatIent Safety Articles

  1. 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. doi: 10.4037/ccn2010473. Epub 2010 Jan 12. PubMed PMID: 20067939.
  2. Westbrook JI, Woods 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. doi: 10.1001/archinternmed.2010.65. PubMed PMID: 20421552.
  3. 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.
  4. 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; PubMed Central PMCID: PMC2464829.

Medication Errors – Chemotherapy

Bibliography of Key Patient Safety Articles

  1. Weingart SN, Toro J, Spencer J, Duncombe D, Gross A, Bartel S, MiranskyJ,Partridge A, Shulman LN, Connor M. Medication errors involving oral chemotherapy. Cancer. 2010 May 15;116(10):2455-64. doi: 10.1002/cncr.25027. PubMed PMID:20225328.
  2. 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.
  3. 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. Review. PubMed PMID: 17468158.
  4. 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. Epub 2005 Nov 7. PubMed PMID: 16275659.
  5. Voeffray M, Pannatier A, Stupp R, Fucina N, Leyvraz S, Wasserfallen JB. Effect of computerization on the quality and safety of chemotherapy prescription. QualSaf Health Care. 2006 Dec;15(6):418-21. PubMed PMID: 17142590; PubMed Central PMCID: PMC2464896.
  6. Schulmeister L. Ten simple strategies to prevent chemotherapy errors. Clin J OncolNurs. 2005 Apr;9(2):201-5. Review. PubMed PMID: 15853163.
  7. Gandhi TK, Bartel SB, Shulman LN, Verrier D, Burdick E, Cleary A, Rothschild JM, Leape LL, Bates DW. Medication safety in the ambulatory chemotherapy setting. Cancer. 2005 Dec 1;104(11):2477-83. PubMed PMID: 16245353.

Medication Use Process

BOOKS

Kirschling TE, ed. The Handbook on Storing and Securing Medications. 2nd ed. Chicago, Illinois: Joint Commission Resources; 2009.

McNeil MJ, ed. ASHP’s Safety and Quality Pearls. Bethesda, MD: American Society of Health-System Pharmacists; 2008. 

Saine DR, ed. ASHP’s Safety and Quality Pearls 2. Bethesda, MD: American Society of Health-System Pharmacists; 2009.   Workman ML, LaCharity LA, Kruchko SL, Understanding Pharmacology: Essentials for Medication Safety.  St. Louis, MI: Saunders, an imprint of Elsvier; 2010.

Bibliography of Key Patient Safety Articles

  1. Meyer-Massetti C, Cheng CM, Schwappach DL, Paulsen L, Ide B, Meier CR, Guglielmo BJ. Systematic review of medication safety assessment methods. Am J Health Syst Pharm. 2011 Feb 1;68(3):227-40. doi: 10.2146/ajhp100019. Review. PubMed PMID: 21258028.
  2. 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. doi: 10.1111/j.1532-5415.2008.01916.x. Epub 2008 Sep 2. PubMed PMID: 18771457; PubMed Central PMCID: PMC3119470.
  3. Skibinski KA, White BA, Lin LI, Dong Y, Wu W. Effects of technological interventions on the safety of a medication-use system. Am J Health Syst Pharm. 2007 Jan 1;64(1):90-6. PubMed PMID: 17189586.
  4. Vermeulen LC, Rough SS, Thielke TS, Shane RR, Ivey MF, Woodward BW, Pierpaoli PG, Thomley SM, Borr CA, Zilz DA. 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. Review. PubMed PMID: 17687058.

Medication Use Process – Prescribing Errors

Bibliography of Key Patient Safety Articles

  1. Barber N. Electronic prescribing--safer, faster, better? J Health Serv Res Policy. 2010 Jan;15 Suppl 1:64-7. doi: 10.1258/jhsrp.2009.09s109. PubMed PMID: 20075133.
  2. 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. doi: 10.2165/00002018-200932050-00002. Review. PubMed PMID: 19419233.
  3. 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.
  4. 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. doi: 10.1331/JAPhA.2008.07031. PubMed PMID: 18595821.

Medication Use Process – Dispensing errors

Bibliography of Key Patient Safety Articles

  1. 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. Review. PubMed PMID: 20218026.
  2. Poon EG, Cina JL, Churchill W, Patel N, Featherstone E, Rothschild JM, Keohane CA, Whittemore AD, Bates DW, Gandhi TK. 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.
  3. Cina JL, Gandhi TK, Churchill W, Fanikos J, McCrea M, Mitton P, Rothschild JM, Featherstone E, Keohane C, Bates DW, Poon EG. How many hospital pharmacy medication dispensing errors go undetected? JtComm J Qual Patient Saf. 2006 Feb;32(2):73-80. PubMed PMID: 16568920.
  4. Paparella S. Automated medication dispensing systems: not error free. J EmergNurs. 2006 Feb;32(1):71-4. PubMed PMID: 16439294.
  5. Anacleto TA, Perini E, Rosa MB, César CC. Medication errors and drug-dispensing systems in a hospital pharmacy. Clinics (Sao Paulo). 2005 Aug;60(4):325-32. Epub 2005 Aug 29. Review. PubMed PMID: 16138240.

Monitoring, Reporting, and Tracking

Bibliography of Key Patient Safety Articles

  1. Hartnell N, MacKinnon N, Sketris I, Fleming M. Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study. BMJ QualSaf. 2012 May;21(5):361-8. doi: 10.1136/bmjqs-2011-000299. Epub 2012 Mar 2. PubMed PMID: 22389018.
  2. Hazell L, Shakir SA. Under-reporting of adverse drug reactions : a systematic review. Drug Saf. 2006;29(5):385-96. Review. PubMed PMID: 16689555.
  3. Szekendi MK, Sullivan C, Bobb A, Feinglass J, Rooney D, Barnard C, Noskin GA. Active surveillance using electronic triggers to detect adverse events in hospitalized patients. QualSaf Health Care. 2006 Jun;15(3):184-90. PubMed PMID: 16751468; PubMed Central PMCID: PMC2464849.
  4. Force MV, Deering L, Hubbe J, Andersen M, Hagemann B, Cooper-Hahn M, Peters W. Effective strategies to increase reporting of medication errors in hospitals. J Nurs Adm. 2006 Jan;36(1):34-41. PubMed PMID: 16404199.
  5. Baer RK. Postmarketing surveillance and reporting of adverse drug events. S D J Med. 2004 Jan;57(1):13-4. Review. PubMed PMID: 14964975.

Patient Safety (Other)

BOOKS

Aspden P, Corrigan JM, Wolcott J. Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academies Press; 2004.

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.

Cousins DD, ed. Advancing Patient Safety in U.S. Hospitals: Basic Strategies for Success. Rockville, MD: US Pharmacopeia; 2004.

Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Patient Safety in Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

Dekker S. Patient Safety: A Human Factors Approach. New York, NY: CRC Press; 2011.

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.

Krug SE, ed. Pediatric Patient Safety in the Emergency Department. Oak Brook, IL: Joint Commission Resources and the American Academy of Pediatrics; 2010.

Pharmacist Role In Medication Safety

BOOKS

Larson CM, Saine D, Medication Safety Officer’s Handbook. Bethesda, MD: American Society of Health-System Pharmacists. 2013.

Bibliography of Key Patient Safety Articles

  1. Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, Graff Zivin J, Abraham I, Palmer J, Martin JR, Kramer SS, Wunz T. US pharmacists' effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010 Oct;48(10):923-33. doi: 10.1097/MLR.0b013e3181e57962. Review. PubMed PMID: 20720510.
  2. Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, Kachalia A, Horng M, Roy CL, McKean SC, Bates DW. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006 Mar 13;166(5):565-71. PubMed PMID: 16534045.
  3. Horn E, Jacobi J. The critical care clinical pharmacist: evolution of an essential team member. Crit Care Med. 2006 Mar;34(3 Suppl):S46-51. Review. PubMed PMID: 16477202.
  4. 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.
  5. Rollason V, Vogt N. Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist. Drugs Aging. 2003;20(11):817-32. Review. PubMed PMID: 12964888.

Second Victim

Bibliography of Key Patient Safety Articles

  1. 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 Oct;18(5):325-30. doi:10.1136/qshc.2009.032870.  PubMed ID:19812092.
  2. Sirriyeh R, Lawton R, Gardner P, Armitage G. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being. Qual Saf Health Care. 2010 Dec;19(6):e43. doi: 10.1136/qshc.2009.035253. Epub 2010 May 3. PubMed PMID 20513788.
  3. Nelson WA, Beyea SC. The role of an ethical culture for the prevention and recovery of "second victims". Qual Saf Health Care. 2009 Oct;18(5):323-4. doi: 10.1136/qshc.2009.034843. Review. PubMed PMID: 19812091.
  4. Edrees HH, Paine LA, Feroli ER, Wu AW. Health care workers as second victims of medical errors. Pol Arch Med Wewn. 2011 Apr;121(4):101-8. Review. PubMed PMID: 21532531.

Sentinel Events

Bibliography of Key Patient Safety Articles

  1. Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008 Feb 13;299(6):685-7. doi: 10.1001/jama.299.6.685. PubMed PMID: 18270357.
  2. Beyea SC. Learning from sentinel event statistics. AORN J. 2004 Aug;80(2):315-8. PubMed PMID: 15382603.
  3. Liang BA, Storti K. Creating problems as part of the "solution": the JCAHO Sentinel Event Policy, legal issues, and patient safety. J Health Law. 2000 Spring;33(2):263-85. Erratum in: J Health Law 2000 Summer;33(3):519. PubMed PMID:11010446.

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