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IMPORTANT NOTE: We are striving to keep this bibliography up-to-date with inclusion of the most significant journal references to scientific (theoretical and empirical) and practice contributions. If you are aware of an important reference that is not on this list, we would appreciate hearing from you so that we can consider adding to the bibliography. Please provide the complete reference in your communication. If possible, please fax the article or an abstract to 215 914 1492. Thank you.


  • Anon. A study of physician's handwriting as a time waster. JAMA 1979. 242:2429-30
  • Perlstein PH, White CC, Barnes B, et al. Errors in drug computations during newborn intensive care. Am J Dis Child. 1979;133:376-9
  • Senders J. Errors...and Error Proofing. Boardroom Reports. 1984, July 15, pg 3-8
  • Forrest L, Davis NM. Use of more than two dosage units as a single adult dose. Hosp Pharm. 1986;21:105-13
  • United States General Accounting Office, Report on medical devices: early warning of problems is hampered by severe under reporting, December 1986
  • Meyer GE, Novelli KA, Smith JE. Use of a refractive index measurement for quality assurance of pediatric parenteral nutrient solution. 1987;44:1617-20
  • Tonges MC. Redesigning hospital nursing practice: The professional advanced care team (ProACT model, Part 1. J of Nursing Admin 1989, vol 19, no 7 (Jul-Aug) p 31-8
  • Cohen MR, Davis NM. Physician order form with lines that will not FAX. Hosp Pharm 1990;25:1099
  • Dahl FC, Davis NM. A survey of hospital policies on verbal orders. Hosp Pharm 1990:25:443-6
  • Lesar TS, Briceland LL, Delcoure K et al. Medication prescribing errors in a teaching hospital. JAMA 1990 May 2; 263(17): 2329-2334
  • Brennan, TA, Leape LL, Laird NM, Herbert ,L et al. Incidence of adverse events and negligence in hospitalized patents: Results of the Harvard medical practice study The New England Journal of Medicine 1991 Feb 7; 324(6): 370-376
  • Cohen MR. Cooperation approaches to medication error management. Top Hosp Pharm Manage; 1991:11(1) 53-65
  • Shafer AL, Lisman RS, Rosenberg MB, Development of a comprehensive operating pharmacy. J Clin Anesth. 1991;3:156-166
  • Vogel DP, Creating the optimal nursing pharmacy interface: A strategic plan for the pharmacy manager. Top Hosp Pharm Manag, 1991, 10(4), 9-22
  • Yee Chin MS, Vogel DP. A team approach to patient care in the medical intensive care units at Robert Wood Johnson University Hospital. Top Hosp Pharm Manage, 1991, 10(4), 83-8
  • Classen DC, Pestotnik SL, Evans RS et al. Description of a computerized adverse drug event monitor using a hospital information system. Hosp Pharm 1992;27:774, 776-9, 783.
  • Cohen MR, Davis NM. Free flow associated with electronic infusion devices: an underestimated danger. Hosp Pharm 1992;27:384-90
  • Davis NM, Cohen MR Teplitsky BS. Look-alike and sound alike drug names: The problem and the solution. Hosp Pharm 1992:27:95-110
  • Kowalski K. From failures to major learning experience. Hosp Pharm 1992;27:851-2 (also appeared in MCN Jan/Feb 1992, Vol # 1, page 9-10
  • Linden JV, Paul B, Dressler KP. A report of 104 transfusion errors in New York State. Transfusion. 1992;32:601-6
  • McCarthy ID, Cohen MR, Kateiva J, McAllister III JC, Ploetz PA. What should a pharmacy manager do when a serious medication error occurs? A panel discussion. Am J Hosp Pharm. 1992;49:1405-12
  • Silverberg JM, Webb B, Pawlak R. Specific gravity-based determination of dextrose content of total parenteral nutrient solutions for neonates. Am J Hosp Pharm.1993:50:2090-1
  • Tucker LL, Cohen MR, Davis NM. Orientation teaching tool to prevent medication error. Hosp Pharm 1994:29:984-91
  • Bates DW, Boyle D, Vander V et al, Relationship between medication errors and adverse drug events. Journal of General Internal Medicine 1995 Apr; 10: 199-205
  • Johnson JA, Bootman JL. Drug-related morbidity and mortality. Arch Intern Med 1995;155:1949-56
  • Schneider PJ, Gift MG, Lee Y et al. Cost of medication-related problems at a university hospital. Am J Health-Syst Pharm. 1995;52:2415-8
  • Wolf ZR. Medication Errors. The Nursing Experience Albany NY. Delmar Publishers 1995
  • Cohen MR, Anderson RW Preventing medication errors in cancer chemotherapy. Am J Health-Syst Pharm 1996;53:37-46
  • Cohen MR, Cohen HG Following a game plan for continued improvement. Nursing96 1996 Nov: 34-37
  • Bates DW, Spell N, Cullen DJ et al. The costs of adverse drug events in hospitalized patients. JAMA 1997 Jan 22/29; 277: 307-311
  • Classen DC, Pestotnik SL, EvansR et al. Adverse drug events in hospitalized patients JAMA 1997 Jan 22/29; 277: 301-306
  • Flynn EA, Pearson RE, Barker KN. Observational study of accuracy in compounding i.v. admixtures at five hospitals. Am J Health-Syst Phram 1997;54: 904-912
  • Lambert, B. Predicting look-alike and sound-alike medication errors. Am J Health-Syst Pharm 1997;54: 1161-1171
  • Lesar, TS, Briceland, L, Stein, DS. Factors related to errors in medication prescribing. JAMA 1997 Jan 22/29; 277: 312-317
  • Bates DW, Leape LL, Cullen DJ et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998;280:1311-16
  • Cohen MR, Proulx SM, Crawford SY. Survey of hospital systems and common srious medication errors. J Healthcare Risk Management. Winter 1998. P16-27
  • Flynn EA, Barker KN, Gibson JT et al. Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy. Am J Health-Syst Pharm 1999;56:1319-25
  • Leape LL, Cullen DJ, Clapp MD et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282:267-270
  • Risser DT, Rice MM, Salisbury ML et al. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med 1999;34:373-83
  • Schulmeister L. Chemotherapy medication errors: Descriptions, severity, and contributing factors. Onc Nursing Forum 1999;26:1033-42
  • Wears RL, Leape LL Human error in emergency medicine. Ann Emerg Med 1999;34:370-372

Contamination of multidose containers

  • Bothe J. Study shows contamination in multidose vials. JOARN 1973;17:111-4
  • Kotheri T et al. Pseudomonas cepecia septic arthritis due to intraarticular injection of methylprednisolone. Can Med Assoc J 1977;166:1230-2
  • Alter MJ et al. Hepatitis B virus transmission associated with a multidose vial in a hemodialysis unit. Ann Int Med 1983;99:330-3
  • Longfield R, Longfield J, Smith LP,Hyams KC, Strolmer ME. Multidose medication vial sterility: An in-use study and review of the literature. InfectionControl;1984;5:165-9
  • Longfield NJ et al. Multidose medication vials sterility; an in use study and a review of the literature. Inf Control 1984;5:165-9
  • Stetler HC et al. Outbreaks of group A streptococcal abscesses following diphtheria-tetanus toxoid-pertussis vaccination. Pediatrics. 1985;75:299-303
  • Langillo BD et al. Canadian Disease Weekly Report 1988; 14:193-5
  • Oren H, et al. A common-source outbreak of fulminant hepatitis B in a hospital. Ann Intern Med 1989;110:691-8
  • Arrington ME et al. Multidose vial contamination in anesthesia. AANA-J. 1990;58:462-6
  • Prott RT, Wagner RF, Trying SK. Iatrogenic contamination of multidose vials in simulated use. Arch Dermatol 1990;126:1441-4 (31 references citing contamination are listed)
  • Improper infection-control practices during employee vaccination programs- District of Columbia and Pennsylvania 1993. Morbidity and Mortality Weekly Report. Dec. 24, 1993; Vol 42;No. 50: pg 969-71
  • Melnyk PS et al. Contamination study of multiple dose vials. Ann Pharmacother 1993;27:274-8
  • Pegues DA, Carson LF, Anderson RL, et al. Outbreak of pseudomonas cepacia bacteremia in oncology patients. Clinical Infectious Disease. 1993;16:407-11.
  • Pettis AM et al. Polymicrobial gram negative bacteremia associated with saline flush used with a needle-free intravenous system. Abs. Am J Infect Cont. 1994;22:103

Medication error rates

  • Barker KN, Mileal RL, Pearson RE, et al. Medication errors in nursing homes and small hospitals. Am J Hosp Pharm. 1982;39:987-91
  • Gaba DM, Maxwell M, DeAnda A. Anesthestic mishaps: Breaking the chain of accident evolution. Anesthesiology 1987: 66;670-6
  • Gaba DM. Human error in anesthesic mishaps. Int Anesth Clin. 1989:27;137-47
  • Allan EL. Barker KN. Fundamentals of medication error research. Am J Hosp Pharm. 1990;47:555-71
  • Davis N. Medication errors: prevention & detection in community pharmacy. Hosp Pharm. 1990;25:18-22, 28
  • Buchanan TL, Barker KN, Gibson JT. Illumination and errors in dispensing. Am J Hosp Pharm. 1991;42: 2137-45
  • Hartwig SC, Dener SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm. 1991;48:2611-6
  • Kuyper A. Patient counseling by pharmacy personnel: a risk management perspective. The IHS Care Provider. 1991;16: No 3;32-5
  • Ciminera JL, Lease MP. Developing control charts to review and monitor medication errors. Hosp Pharm. 1992;27:192-3, 195-7
  • Gold DR, Rogacz S, Bock N, et al. Rotating shift work, sleep, and accident related to sleepiness in hospital nurses. Am J Public Health.1992;82:1011-14
  • Kuyper A. Patient counseling detects prescription errors. Hosp Pharm.1993;28:1181-89
  • New York State Department of Health. Bureau of Hospital Services. Hospital Incident Reporting Program Annual Reports. 1989-93. Albany, New York. (tel. 518-402-1010).
  • Davis, NM, Cohen MR. Is our medication error rate acceptable? Hosp Pharm. 1994;29:980. 993
  • Schneider PJ, Hartwig SC. Use of severity-indexed medication error reports to improve quality. Hosp Pharm.1994;29:205-11
  • Cohen MR, Crawford SY. Benchmarking project to reduce medication errors Phase I. Presented at ASHP MidYear Clinical Meeting,1995, Las Vegas, NV
  • Dean BS, Allan E, Barber, ND, Barker, KN. Comparison of medication errors in an American and a British Hospital American Journal of Health-System Pharmacy 1995 Nov 15; 52: 2543-2549
  • Ruffin DM, Hodge FJ. Pharmacist’s impact on medication administration errors in long-term care facilities. Consult Pharm 1995;10:1025-1032
  • Lazarou J, Pomeranz BH, Corey, PN. Incidence of adverse drug reactions in hospitalized patients: A meta-analysis of prospective studies JAMA 1998 Apr 15; 279(15): 1200-1205
  • Phillips DP,Christenfeld N,Glyn LM.Increase in U.S. medication-error death between 1983 and 1993.The Lancet 1998 Feb 28; 352: 643-644

General reference material

  • Cohen MR. Medication error reports. Hosp Pharm. 1975;10:120- to the present (appearing 10-12 times a year).
  • Cohen MR. Medication error reports. Nursing 79 to the present, monthly
  • Cohen MR. Discrepancies in unit dose cart fills. Hosp Pharm. 1980;15:17-19
  • Davis NM, Cohen MR. Medication errors: Causes and prevention. Neil M. Davis Assoc. Huntingdon Valley, PA., 19006, 1981, $26.00 (215-947-1752)
  • Cobb MD. Evaluating medication errors. Hosp Pharm. 1986;21:925-9
  • Folli HL, Poole RL, Benitz WE. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics 1987; 79, 718-22
  • Norman DA. The psychology of everyday things. New York, NY: Basic Books; 1988
  • Subolish NL, Cohen MR. A checklist for nursing orientation to pharmacy services. Hosp Pharm 1988;23:664-6
  • American Society of Consultant Pharmacists. Detecting and counting medication errors in long term care facilities. 1987, 2300 Ninth Street South, Arlington, VA 22204. $20.00 (701 920-8492)
  • Davis, NM. Detection and prevention of ambulatory dispensing errors. Hosp Pharm. 1990;25:18-28
  • Senders JW, Neville PM. Human errors; their causes, prediction, and reduction. Lawrence Erlbaum Associates, Inc., Hilldale NJ, 1991
  • Cohen MR, Davis NM. Developing safe and effective preprinted physician=s order forms. Hosp Pharm. 1992;27:508, 513, 528
  • McCarthy ID, Cohen MR, Kateiva J, McAllister JC, Ploetz PA. What should a pharmacy manager do when a serious medication error occurs? A panel discussion. Am J Hosp Pharm. 1992;49:1405-12
  • ASHP guideline on preventing medication errors in hospitals. Am J Hosp Pharm. 1993;50:305-14
  • Lane C, Goldman L, Soulkup JR, Hayes JG. The impact of a regulation restricting medical house staff working hours on the quality of patient care. JAMA.1993;269:374 (The study indicated that patient care worsened.)
  • Tierney WH, Miller ME. Overage JM. McDonald CJ. Physician inpatient order writing on microcomputer workstations. JAMA. 1993:269;379-83
  • Baker KR, Mondt D. Risk management in pharmacy: preventing liability claims. American Pharmacy. 1994; NS34, No. 10(Oct):60-71
  • Cohen MR ed. Medication Errors. Washington. American Pharmaceutical Association 1999

Pediatric medication errors

  • Perlstein PH, Callison C, White M, et al. Errors in drug computations during newborn intensive care. Am J Dis Child. 1979;133:376-79
  • Shane R, Quon LM. Prevention of medication errors in pediatrics. Am J Dis Child. 1981;135:384
  • Walson P, Hammel M, Martin R. Prescription writing by pediatric house officers. J Med Ed. 1981;56:423-8
  • Koren G, Barzilay Z, Modan M. Errors in computing drug doses. CMAJ. 1983;129:721-23
  • Rosati JR, Nahata MC, Drug administration errors in pediatric patients. QRB. 1983:212-213
  • Solomon S, Wallace E, Ford-Jones E, et al. Medication errors with inhalant epinephrine mimicking an epidemic of neonatal sepsis. N Engl J Med. 1984;310:166
  • Buehler JW, Smith LF, Wallace EM, et al. Unexplained deaths in a children’s hospital. An epidemiologic assessment. N Engl J Med. 1985;313:211-6
  • Koren G, Barzilay Z, Greenwald M. Tenfold errors in administration of drug doses: A neglected iatrogenic disease in pediatrics. Pediatrics. 1986;77:848
  • Folli HL, Poole RL, Benitz WE et al. Medication error prevention by clinical pharmacists in two children=s hospitals. Pediatrics. 1987;79:718-22
  • McClead RE, Menke JA. Neonatal Iatrogenesis. Adv Pediatr. 1987;34:335-56
  • Bayne T, Bindler R. Medication calculation skills of registered nurses. J Cont Ed Nursing. 1988;19:258-262
  • Nahata MC. Paediatric drug therapy II-Drug administration errors. J. Clin Pharm Ther. 1988;13:399-402
  • Rieder MJ, Goldstein D, Zinman H, et al. Tenfold errors in drug dosage. CMAJ.1988;139:12-13
  • A quality assurance activity. Am J Dis Child. 1989;143:737-40
  • Raju TNK, Thornton JP, Kecskes S, et al.. Medication errors in neonatal and pediatric intensive care units. Lancet. 1989 (Aug 12);374-6
  • Bindler R, Bayne T. Medication calculation ability of registered nurses. Image: J Nurs Scholar. 1991;23:221-24
  • Characteristics of medication errors in pediatrics. DICP. 1991;25:1113-17
  • Institute for Safe Medication Practices and Pediatric Pharmacy Advocacy Group. Draft guidelines for preventing medication errors in pediatrics. J Ped Pharm Practice. 1998;3:189-202
  • Jonville A-P, Autret E, Bavoux F, et al.
  • Vincer MJ, Murray JM, Yuill A, et al. Drug errors and incidents in a neonatal intensive care unit.

Failure Mode And Effects Analysis (FMEA)

  • Cohen MR, Senders J, Davis NM. Failure mode and effects analysis: A novel approach to avoiding dangerous medication errors and accidents. Hosp Pharm 1994; 29:319-30
  • Cohen MR, Senders J, Davis NM. 12 Ways to prevent medication errors. Nursing 94 1994;24:34-41
  • Cohen MR, Senders J, Davis NM. Failure mode and effects analysis: Dealing with human error. Nursing 94 1994;24:40
  • Leape LL. Error in medicine. JAMA 1994;272:1851-57
  • Williams, E, Talley T. The use of failure mode effect and criticality analysis in a medication error subcommittee. Hosp Pharm 1994; 29:331-38
  • Leape LL, Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43

Errors with automation

  • Manzelli TA. Utilization of the Brewer system in the controlled distribution of medication within the hospital. Am J Hosp Pharm 1961;18:560-6
  • Barker KN, Pearson RE, Helper CD et al. Effect of an automated bedside dispensing machine on medication errors. Am J Hosp Pharm 1984;41:1352-8
  • Barker KN. Research on drug use system errors. Am J Health-Syst Pharm. 1995;52:400-403
  • Borel JM, Rascati KL. Effects of an automated, nursing unit-based drug dispensing device on medication errors. Am J Health-Syst Pharm. 1995;52:1875-9
  • Buchanan EC. Ethics of automated compounding and dispensing. Pharm. Pract Manage Q 1995;15(3):1-6
  • Barker KN. Assuring safety in the use of automated medication dispensing systems. Am J Health-Syst Pharm 1995;52:2445-7
  • Magnus GH. Frontline pharmacist. Preparing for automated dispensing devices. Am J Health-Syst Pharm 1995;52:2406-08

Inservice and other educational material

  • Cohen MR. Ed. Medication Errors. American Pharmaceutical Association, Washington DC 1999
  • Medication errors: A closer look. A 20 minute Video. American Society of Hospital Pharmacists. Bethesda, MD. VHS: $100.00; 3/4": $125.00 (301-657-3000)
  • Davis NM. Medical Abbreviations: 15,000 Conveniences at the Expense of Safety and Communications. Neil M. Davis Assoc., Huntingdon Valley, PA 19006. 1999. (215-947-1752)
  • UDL Laboratories. Generic-Brand Handbook. P.O. Box 10319, Rockford, IL 61131-3019. (800)-435-5272).
  • Medication Pass. 1992, a 20 minute video tape. American Society of Consultant Pharmacists. VHS 2300 Ninth Street South, Arlington, VA 22204. (701 920-8492)
  • Reducing Medication Errors Through Failure Mode and Effects Analysis. A 22 minute video. The Center for Proper Medication Use, Phila., PA VHS $125.00 (215-895-1131)
  • Med Pass Survey: A continuous quality improvement approach (medication pass observation to detect medication error rates) American Society of Consultant Pharmacists, 2300 Ninth Street South, Arlington, VA 22204. (701 920-8492)
  • Beyond Blame. A videotape about the value of nonpunitive error reporting environments. Available for $10 from Bridge Medical, 120 South Sierra, Solana Beach, CA 92075-4811. (619) 350-0100.
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