thors were asked to review this literature from the last 10 years2 (and earlier major studies if still relevant). Where possible, the five steps in the medication-use process were to be analyzed separately. Special attention was to be given to errors that arise during transfers between care settings, for example, from hospital to ambulatory care. In addition, the authors were asked to identify the approaches to reducing medication errors recommended by major health care organizations and to evaluate each approach in terms of the evidence/process used by these organizations to justify it. In addition, a paper was commissioned to review the non-peer-reviewed literature for approaches to reducing medication errors.3 The authors of the commissioned papers were encouraged to use a modified search strategy as described by Smeaton and colleagues (2002). They were also encouraged to search the following databases: MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, IPA (International Pharmaceutical Abstracts), Science Citation Index, and Dissertation Abstracts. The authors tailored these suggestions to their own requirements. In summary, the study focused on English-language articles published in the period 1995–2005, augmented by earlier important studies and studies published after the literature reviews had been completed. The majority of studies reviewed were conducted in the United States. Where relevant, when there were no or few U.S. studies for a particular setting or study category, foreign studies are cited in the report, with the country of origin noted.

Drawing on these commissioned papers, this chapter summarizes the committee’s findings on the incidence and costs of medication errors (more detail on incidence is given Appendix C). Chapter 5 summarizes the committee’s findings on prevention strategies as part of the recommended action agendas for each care setting (more detail on these strategies is given in Appendix D).


The extent of the research on the incidence of medication errors and adverse drug events (ADEs) varies greatly across care settings (see Appendix C); Box 3-1 summarizes the difficulties encountered by the committee

College of Medicine; for pediatric care, Marlene R. Miller, MD, MSc, Karen A. Robinson, MSc, Lisa H. Lubornski, PhD, Michael L. Rinke, BA, and Peter J. Pronovost, MD, PhD, The Johns Hopkins University; for psychiatric care, Benjamin C. Grasso, MD, The Institute for Self-Directed Care; and for OTC and complementary and alternative medications, Albert I. Wertheimer, MBA, PhD and Thomas M. Santella, BS, Temple University.


The pediatric care paper examined peer-reviewed journals over the last 5 years.


Authored by Eta Berner, EdD, University of Alabama at Birmingham, and Richard Maisiak, PhD, MSPH, consultant.

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