Works Cited

1. Fink JL. Dispensing Wrong Medications Leads to Patient's Death. https://www.pharmacytimes.com/view/dispensing-wrong-medications-leads-to-patients-death. (Accessed September 27, 2023).

2. World Health Organization. WHO launches global effort to halve medication-related errors in 5 years. March 2017. https://www.who.int/news-room/detail/29-03-2017-who-launches-global-effort-to-halve-medication-related-errors-in-5-years. (Accessed September 27, 2023).

3. Desjardins L. Thousands die from medical errors yearly, notes advocacy group. October 2019. https://www.rcinet.ca/en/2019/10/28/thousands-die-from-medical-errors-yearly-notes-advocacy-group/. (Accessed September 27, 2023).

4. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press (U.S.); 2000.

5. Harvey HB, Sotardi ST. The Just Culture framework. J Am Coll Radiol. 2017;14:1239-41. PMID 28633924.

6. Hutton B, Kanji S, McDonald E, et al. Incidence, causes, and consequences of preventable adverse drug events: protocol for an overview of reviews. Syst Rev. 2016;5:209. PMID 27919281.

7. Bourgeois FT, Shannon MW, Valim C, Mandl KD. Adverse drug events in the outpatient setting: an 11-year national analysis. Pharmacoepidemiol Drug Saf. 2010;19:901-10. PMID 20623513.

8. US Food and Drug Administration. Safe Use Initiative. August 2022. https://www.fda.gov/drugs/drug-safety-and-availability/safe-use-initiative. (Accessed September 27, 2023).

9. US Food and Drug Administration. Safe Use Initiative – Current Projects. October 2019. https://www.fda.gov/drugs/safe-use-initiative/safe-use-initiative-current-projects. (Accessed September 27, 2023).

10. ISMP Canada. Canadian Medication Incident Reporting and Prevention System (CMIRPS). https://www.ismp-canada.org/cmirps/. (Accessed September 27, 2023).

11. National Coordinating Council for Medication Error Reporting and Prevention. What is a Medication Error? http://www.nccmerp.org/about-medication-errors. (Accessed August 17, 2023).

12. National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to enhance accuracy of dispensing medications. June 2015. https://www.nccmerp.org/recommendations-enhance-accuracy-dispensing-medications. (Accessed September 27, 2023).

13. ISMP. ISMP survey helps define near miss and close call. September 24, 2009. https://www.ismp.org. (Accessed August 17, 2023).

14. Agency for Healthcare Research and Quality. Patient Safety Network. Glossary. https://psnet.ahrq.gov/glossary. (Accessed September 27, 2023).

15. Hughes RG, Blegen MA. Medication Administration Safety. In: Hughes RF, Ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality, 2008.

16. Winterstein AG, Johns TE, Rosenberg EI, et al. Nature and causes of clinically significant medication errors in a tertiary care hospital. Am J Health Syst Pharm. 2004;61:1908-16. PMID: 15487880.

17. Healthcare Providers Service Organization. Pharmacist Professional Liability Exposure Claim Report: 3rd Edition. https://www.hpso.com/getmedia/261a3590-6368-41e6-857c-f2bf9dbdf6ea/CNA_CLS_PHARM_072823_CF_PROD_SEC-(1).pdf. (Accessed September 28, 2023).

18. Abramson EL, Bates DW, Jenter C, et al. Ambulatory prescribing errors among community-based providers in two states. J Am Med Inform Assoc. 2012;19:644e648. PMID: 22140209.

19. Kennedy AG, Littenberg B. A modified outpatient prescription form to reduce prescription errors. Jt Comm J Qual Saf. 2004;30:480-7. PMID: 15469125.

20. National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to enhance accuracy of prescription/medication order writing. October 2014. https://www.nccmerp.org/recommendations-enhance-accuracy-prescription-writing. (Accessed September 28, 2023).

21. Simons FE. Anaphylaxis. J Allergy Clin Immunol. 2010;125(2 Suppl 2):S161-81. PMID: 20176258.

22. Jani YH, Ghaleb MA, Marks SD, et al. Electronic prescribing reduced prescribing errors in a pediatric renal outpatient clinic. J Pediatr. 2008;152:214-8. PMID: 18206691.

23. Phillips JL, Shea JM, Leung V, MacDonald D. Impact of early electronic prescribing on pharmacists' clarification calls in four community pharmacies located in St John's, Newfoundland. JMIR Med Inform. 2015;3:e2. PMID 25595165.

24. Surescripts. 2022 National Progress Report. https://surescripts.widen.net/s/mvtqvvf5sd/2022-national-progress-report. (Accessed September 28, 2023).

25. Centers for Medicare & Medicaid Services. EPCS: Electronic Prescribing for Controlled Substances Frequently Asked Questions. https://www.cms.gov/files/document/epcs-frequently-asked-questions.pdf-0. (Accessed September 28, 2023).

26. PrescribeIT. About Us. https://www.prescribeit.ca/about-us. (Accessed September 28, 2023).

27. Carrillo-Martin I, Gonzalez-Estrada A, Funni SA, et al. Increasing allergy-related emergency department visits in the United States, 2007 to 2015. J Allergy Clin Immunol Pract. 2020;8:2983-8. PMID 32553832.

28. Rogers E, Griffin E, Carnie W, et al. A Just Culture approach to managing medication errors. Hosp Pharm. 2017;52:308-15. PMID 28515512

29. ISMP. Just Culture and its critical link to patient safety (part I). May 17, 2012. https://www.ismp.org. (Accessed August 17, 2023).

30. The Joint Commission. Do Not Use List Fact Sheet. https://www.jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-do-not-use-list/. (Accessed August 25, 2023).

31. Cohen MR. ISMP medication error report analysis: hazardous abbreviation for "intranasal." Hosp Pharm. 2003;38:1004-5.

32. ISMP. List of Error-Prone Abbreviations. February 5, 2021. https://www.ismp.org. (Accessed August 25, 2023).

33. Li Q, Kawano A, Ho C. Look-alike/sound-alike drug names. February 2016. https://www.ismp-canada.org. (Accessed September 29, 2023).

34. ISMP. List of Confused Drug Names. July 26, 2023. https://www.ismp.org. (Accessed August 25, 2023).

35. US Food and Drug Administration. FDA Drug Safety Communication: Important change to heparin container labels to clearly state the total drug strength. December 2012. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-important-change-heparin-container-labels-clearly-state-total-drug. (Accessed September 29, 2023).

36. US Food and Drug Administration. Working to Reduce Medication Errors. August 2019. https://www.fda.gov/drugs/drug-information-consumers/working-reduce-medication-errors. (Accessed September 29, 2023).

37. Takeda. Kapdiex (dexlansoprazole) Renamed Dexilant in U.S. to Avoid Name Confusion. March 2010. https://www.takeda.com/en-us/newsroom/news-releases/2010/kapidex-dexlansoprazole-renamed-dexilant-in-u.s.-to-avoid-name-confusion/. (Accessed September 29, 2023).

38. US Food and Drug Administration. FDA Drug Safety Communication: FDA approves brand name change for antidepressant drug Brintellix (vortioxetine) to avoid confusion with antiplatelet drug Brilinta (ticagrelor). May 2016. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-approves-brand-name-change-antidepressant-drug-brintellix. (Accessed September 29, 2023).

39. ISMP. Look-Alike Drug Names with Recommended Tall Man (Mixed Case) Letters. January 26, 2023. https://www.ismp.org. (Accessed September 29, 2023).

40. Cohen MR. Something's lost in translation. Nursing 2005;35(12). https://journals.lww.com/nursing/Fulltext/2005/05000/Something_s_lost_in_translation.8.aspx. (Accessed September 29, 2023).

41. Anthony S. Avoiding Problems: Managing the Risks in Hospital Practice. May 2012. https://www.medicalprotection.org/ireland/booklets/avoiding-problems-managing-the-risks-in-hospital-practice. (Accessed September 29, 2023).

42. National Coordinating Council for Medication Error Reporting and Prevention. Recommendation for Manufacturers, Regulators, and Standards Setters to Promote the Safe Use of Modifiers in Prescription Drug Proprietary (Brand) Names. March 2023. http://www.nccmerp.org/recommendation-manufacturers-regulators-and-standards-setters-promote-safe-use-modifiers. (Accessed September 29, 2023).

43. US Food and Drug Administration. Postmarket Information – Device Surveillance and Reporting Processes. September 2018. https://www.fda.gov/medical-devices/human-factors-and-medical-devices/postmarket-information-device-surveillance-and-reporting-processes. (Accessed September 29, 2023).

44. Lehne RA. Drug Regulation, Development, Names, and Information. In: Pharmacology for Nursing Care. 8th Ed. St. Louis, MO: Elsevier Saunders, 2013:22.

45. Drugs.com. Zertalin. https://www.drugs.com/international/zertalin.html. (Accessed September 29, 2023).

46. National Coordinating Council for Medication Error Reporting and Prevention. Reducing Medication Errors Associated with At-risk Behaviors by Healthcare Professionals. August 2014. https://www.nccmerp.org/reducing-medication-errors-associated-risk-behaviors-healthcare-professionals. (Accessed September 29, 2023).

47. van der Sijs H, Mulder A, van Gelder T, et al. Drug safety alert generation and overriding in a large Dutch university medical centre. Pharmacoepidemiol Drug Saf. 2009;18:941-7. PMID 19579216

48. Affrime MB, Lowenthal DT, Tobert JA, Shirk J, Eidelson B, Cook T, Onesti G. Dynamics and kinetics of ophthalmic timolol. Clin Pharmacol Ther. 1980 Apr;27(4):471-7.

49. Alvan G, Calissendorff B, Seideman P, Widmark K, Widmark G. Absorption of ocular timolol. Clin Pharmacokinet. 1980 Jan-Feb;5(1):95-100.

50. Foong AL, Grindrod KA, Patel T, Kellar J. Demystifying serotonin syndrome (or serotonin toxicity). Can Fam Physician. 2018 Oct;64(10):720-727.

51. Foong AL, Patel T, Kellar J, Grindrod KA. The scoop on serotonin syndrome. Can Pharm J (Ott). 2018 May 30;151(4):233-239.

52. Scotton WJ, Hill LJ, Williams AC, Barnes NM. Serotonin Syndrome: Pathophysiology, Clinical Features, Management, and Potential Future Directions. Int J Tryptophan Res. 2019 Sep 9;12:1178646919873925.

53. Baldo BA, Rose MA. The anaesthetist, opioid analgesic drugs, and serotonin toxicity: a mechanistic and clinical review. Br J Anaesth. 2020 Jan;124(1):44-62.

54. Curtis KM, Tepper NK, Jatlaoui TC, Berry-Bibee E, Horton LG, Zapata LB, Simmons KB, Pagano HP, Jamieson DJ, Whiteman MK. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016 Jul 29;65(3):1-103.

55. Grasha A. Cognitive systems perspective on human performance in the pharmacy: implications for accuracy, effectiveness, and job satisfaction (Report No. 062100). Alexandria, VA: NACDS. 2000.

56. National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to reduce medication errors associated with verbal medication orders and prescriptions. May 2015. https://www.nccmerp.org/recommendations-reduce-medication-errors-associated-verbal-medication-orders-and-prescriptions. (Accessed October 3, 2023).

57. ISMP. Despite Technology, Verbal Orders Persist, Read Back is Not Widespread, and Errors Continue. May 18, 2017. https://www.ismp.org/. (Accessed October 3, 2023).

58. Svarstad BL, Mount JK, Tabak ER. Expert and consumer evaluation of patient medication leaflets provided in U.S. pharmacies. J Am Pharm Assoc. (2003) 2005;45:443-51. PMID 16128499.

59. Cutilli CC, Bennett IM. Understanding the health literacy of America: results of the National Assessment of Adult Literacy. Orthop Nurs. 2009;28:27-32. PMID 19190475.

60. Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med. 1997;157:1569-76. PMID 9236558.

61. Suh DC, Woodall BS, Shin SK, Hermes-De Santis ER. Clinical and economic impact of adverse drug reactions in hospitalized patients. Ann Pharmacother. 2000;34:1373-9. PMID 11144691.

62. ISMP. High-alert medications in acute care settings. August 23, 2018. https://www.ismp.org. (Accessed August 25, 2023).

63. ISMP. High-alert medications in community/ambulatory care settings. September 30, 2021. https://www.ismp.org. (Accessed August 25, 2023).

64. Weingart SN, Toro J, Spencer J, et al. Medication errors involving oral chemotherapy. Cancer. 2010;116:2455-64. PMID: 20225328.

65. Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111:722-9. PMID 12671103.

66. Torjesen I. How do we ensure pharmacist have the skills they need for their expanding role? August 2015. https://pharmaceutical-journal.com/article/news/how-do-we-ensure-pharmacists-have-the-skills-they-need-for-their-expanding-role. (Accessed October 4, 2023).

67. Institute for Healthcare Improvement. Involve patients in medication checks. http://www.ihi.org/resources/Pages/Changes/InvolvePatientsinMedicationChecks.aspx. (Accessed October 4, 2023).

68. Alberta Health Services. Know your medicines. February 2021. https://myhealth.alberta.ca/Alberta/Pages/know-your-medications.aspx. (Accessed October 4, 2023).

69. ISMP Canada. Informed patients can reduce risk of medication errors. October 2000. https://www.ismp-canada.org/. (Accessed October 4, 2023).

70. Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences and contributing factors.Int J Med Inform. 2014;83:427–37. PMID: 24657055

71. Leapfrog Group. Factsheet: computerized physician order entry. April 2020. https://www.leapfroggroup.org/sites/default/files/Files/2020%20CPOE%20Fact%20Sheet.pdf. (Accessed October 4, 2023).

72. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293:1197-203. PMID: 15755942.

73. ISMP Canada, Canada Patient Safety Institute. Medication bar code system implementation planning: A resource guide. September 2013. https://www.ismp-canada.org/barcoding/download/ResourceGuide/BarCodingResourceGuideFINAL.pdf. (Accessed October 4, 2023).

74. The Joint Commission. Transitions of care: managing medications. August 2016. https://www.jointcommission.org/-/media/tjc/documents/newsletters/quick-safety-issue-26-aug-2016-final-8-24-16.pdf. (Accessed October 4, 2023).

75. Tam VC, Knowles SR, Cornish PL, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173:510-5. PMID: 16129874.

76. Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care. 2005;17:15-22. PMID: 15668306.

77. Polnariev A. What to do when you make a medication error. September 2016. https://www.pharmacytimes.com/contributor/alan-polnariev-pharmd-ms-cgp/2016/09/what-to-do-when-you-make-a-medication-error. (Accessed October 4, 2023).

78. ISMP. Improving medication safety in community pharmacy: assessing risk and opportunities for change. February 5, 2009. https://www.ismp.org/. (Accessed October 4, 2023).

79. Grissinger M. Too many abandon the "second victims" of medical errors. P T. 2014;39:591-2. PMID 25210409.

80. Quiring V. How to respond when a medication error occurs. J Am Pharm Assoc. 2001;41:s54-5.

81. Agency for Healthcare Research and Quality. Root cause analysis. September 2019. https://psnet.ahrq.gov/primer/root-cause-analysis?q=/primers/primer/10. (Accessed October 4, 2023).


Copyright © 2023 NetCE, PO Box 997571, Sacramento, CA 95899-7571
Mention of commercial products does not indicate endorsement.