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PATIENT SAFETY PRIMERS
Never Events
Systems Approach
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STUDY
A comparison of voluntarily reported medication errors in intensive care and general care units.
Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.
STUDY
Medication error reporting in nursing homes: identifying targets for patient safety improvement.
Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.
COMMENTARY
Dealing honestly with an honest mistake.
Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.
COMMENTARY
Medication errors related to product names.
Santell JP, Cousins DD. Jt Comm J Qual Patient Saf. 2005;31:649-654.
COMMENTARY
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2006;41:405-406.
STUDY
Computer based medication error reporting: insights and implications.
Miller MR, Clark JS, Lehmann CU. Qual Saf Health Care. 2006;15:208-213.
NEWSPAPER/MAGAZINE ARTICLE
Ding-a-ling-a-ling: ambulances can be dangerous places.
Meisel Z. Slate. November 8, 2005.
COMMENTARY
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2005;40:940-945.
COMMENTARY
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2006;41:114-117.
COMMENTARY
Between a rock and a hard place: disclosing medical errors.
Crone KG, Muraski MB, Skeel JD, Love-Gregory L, Ladenson JH, Gronowski AM. Clin Chem. 2006;52:1809-1814.
COMMENTARY
Using medical-error reporting to drive patient safety efforts.
Stow J. AORN J. 2006;84:406-408, 411-414, 417-420.
STUDY
Inadvertent misadministration of meningococcal conjugate vaccine—United States, June–August 2005.
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2006;55:1016-1017.
STUDY
Towards safer neonatal transfer: the importance of critical incident review.
Moss SJ, Embleton ND, Fenton AC. Arch Dis Child. 2005;90:729-732.
NEWSPAPER/MAGAZINE ARTICLE
Generic drug names: fertile ground for errors?
Wynn P. Drug Topics Supplements. August 8, 2005.
COMMENTARY
The Role of the Patient in Improving Patient Safety
Gibson R. AHRQ WebM&M [serial online]. March 2007.
MULTI-USE WEBSITE
ISMP QuarterWatch Reports.
Institute for Safe Medication Practices.
NEWSPAPER/MAGAZINE ARTICLE
ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2008;13:1-3.
STUDY
Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.
Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.
STUDY
Disclosing harmful mammography errors to patients.
Gallagher TH, Cook AJ, Brenner RJ, et al. Radiology. 2009;253:443-452.
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