Weber LM, Ghafoor VL, Phelps P. Implementation of standard order sets for patient-controlled analgesia. American Journal of Health-System Pharmacy. 2008 Jun 15;65(12):1184-1191.

This case study describes the development and implementation of standard order sets to improve the safety of opioid-based patient-controlled analgesia (PCA). Post-intervention assessment showed that the implementation of standard order sets sharply reduced the incidence of PCA-associated respiratory depression. Changing the order sets to improve medication safety did not appear to negatively affect patient satisfaction with pain management.

Kaushal R, Bates DW, Abramson EL, Soukup JR, Goldmann DA. Unit-based clinical pharmacists’ prevention of serious medication errors in pediatric inpatients. American Journal of Health-System Pharmacy. 2008 Jul 1;(65)13:1254-1260.

This study measured rates of serious medication errors in three pediatric inpatient units (intensive care, general medical, and general surgical) before and after introduction of unit-based clinical pharmacists. The authors conclude that a full-time unit-based clinical pharmacist substantially decreased the rate of serious medication errors in a pediatric ICU, but a part-time pharmacist was not as effective in decreasing errors in pediatric general care units.

Cohen H. Protecting patients from harm: Reduce the risks of high-alert drugs. Nursing2007. 2007 Sept;37(9):49-55.

Learn how adapting processes for prescribing, preparing, and administering can help reduce errors associated with certain high-alert medications. This article is part of a series that describes the IHI's 5 Million Lives Campaign recommended interventions from a front-line nursing perspective.

Federico F. Preventing harm from high-alert medication. Joint Commission Journal on Quality and Patient Safety. 2007 Sept;33(9):537-542.

The author describes the Institute for Healthcare Improvement 5 Million Lives Campaign intervention to prevent patient harm from high-alert medications, starting with a focus on anticoagulants, sedatives, narcotics, and insulin. This article is the second in a series on the 5 Million Lives Campaign.

Meisel M, Meisel S. Best-practice protocols: Reducing harm from high-alert medications. Nursing Management. 2007 July;38(7):31-39.

This second article in a series describes reducing harm to patients from high-alert medications by reviewing a case study on the importance of postoperative monitoring of opioid-naive patients who are receiving narcotics. The series presents a nursing management perspective on the six interventions recommended by the Institute for Healthcare Improvement as part of its 5 Million Lives Campaign to protect patients from five million incidents of medical harm over a two-year period.

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Elixhauser A, Owens P. Adverse Drug Events in US Hospitals (2004). Healthcare Cost and Utilization Panel (HCUP) Statistical Report #29. Rockville, Maryland: Agency for Healthcare Research and Quality; April 2007.

This report, based on 2004 Healthcare Cost and Utilization Panel (HCUP) data, describes the types of patients seen with adverse drug events (ADEs) in US hospitals as well as the types of ADEs reported. The data indicated that ADEs were found in approximately 3.1 percent of all hospital stays, and most ADEs (90.3 percent) were attributed to the side effects of properly administered medications.

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Varkey P, Cunningham J, Bisping DS. Improving medication reconciliation in the outpatient setting. Joint Commission Journal on Quality and Patient Safety. May 2007;33(5):286-292.

This article describes a systematic study into outpatient medication reconciliation to determine if a multifaceted intervention influencing providers and patients reduced discrepancies related to inadequate prescription medication reconciliation in an outpatient setting.

Varkey P, Cunningham J, O'Meara J, Bonacci R, Desai N, Sheeler R. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. American Journal of Health-System Pharmacy. 2007 Apr 15;64(8):850-854.

The mean number of medication discrepancies occurring during admission and discharge decreased after a multidisciplinary medication reconciliation process (involving nurses, physicians, pharmacists, and family medicine residents and staff) was implemented in an inpatient family medicine unit of an academic hospital center.

Varkey P, Resar RK. Medication reconciliation implementation in an academic center. American Journal of Medical Quality. 2006 Sep-Oct;21(5):293-235.

The authors describe the evolution and implementation of the inpatient medication reconciliation process at Mayo Clinic, an academic tertiary care center based in Rochester, Minnesota, composed of 3 integrated hospitals, receiving 60,000 admissions per year to a total of 1,951 beds. A pilot project was initiated and tested in the family medicine hospital service in April 2005. As the pilot project was implemented, several key concepts surfaced as being critical for expansion to the whole organization.

Kramer JS, Hopkins PJ, Rosendale JC, et al. Implementation of an electronic system for medication reconciliation. American Journal of Health System Pharmacy. 2007 Feb 15;64(4):404-422.

The authors studied the feasibility of implementing an electronic system for targeted pharmacist- and nurse-conducted admission and discharge medication reconciliation and its effects on patient safety, cost, and satisfaction. They concluded that patients who had their medications electronically reconciled reported a greater understanding of the medications they were to take after discharge from the hospital, including medication administration instructions and potential adverse effects.