Pryor DB, Tolchin SF, Hendrich A, Thomas CS, Tersigni AR. The clinical transformation of Ascension Health: Eliminating all preventable injuries and deaths. Joint Commission Journal on Quality and Patient Safety. 2006 June;32(6):299-308.

In 2002 Ascension Health, a 67-hospital not-for-profit health care system, embarked on a journey of clinical transformation to eliminate preventable injuries or deaths. This transformational change implies a much greater pace of change than that reflected in traditional, incremental change processes. Their improvement activities focused on eight priorities for action: JCAHO National Patient Safety Goals; preventable mortality; adverse drug events; falls; pressure ulcers; surgical complications; nosocomial infections; and perinatal safety. [This article is the first in a series.]

Full text available. Click view article below.

McCarthy D, Blumenthal D. Committed to Safety: Ten Case Studies on Reducing Harm to Patients. The Commonwealth Fund. April 2006; Publication No. 923.

This report presents ten case studies of health care organizations, clinical teams, and learning collaborations that have designed innovations in five areas that hold great promise for improving patient safety nationally: promoting an organizational culture of safety; improving teamwork and communication; enhancing rapid response to prevent heart attacks and other crises in hospitals; preventing health care-associated infections in the intensive care unit; and preventing adverse drug events throughout the hospital.

Full text available! Click view report below.

Manno M, Hayes DD. How medication reconciliation saves lives. Nursing2006. Mar 2006;36(3):63-64.

Medication reconciliation is defined by IHI’s 100,000 Lives Campaign as “the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medication to the patient at all transition points within the hospital.” It’s also among the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO’s) 2006 National Patient Safety Goals. In this article, the authors explain how medication reconciliation works and offers tips about compiling accurate and complete lists.

Full text available! Click View Article below.

Institute for Family-Centered Care. Your role in safe medication use. Massachusetts Coalition for the Prevention of Medical Errors; 1999.

This consumer guide encourages patients to become "part of the health care team" along with their physicians, nurses, and pharmacists, to prevent medication mistakes. The guide was developed in conjunction with the Institute for Family-Centered Care and is based on input solicited from patients, families, and health care professionals. Available in both English and Spanish.

Full text available! Click view guide below.

Using medication reconciliation to prevent errors. Sentinel Event Alert, Issue 35. Joint Commission on Accreditation of Healthcare Organizations’ Sentinel Event Alert. [Serial online]. January 25, 2006.

This alert from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) discusses the benefits of medication reconciliation in reducing medication errors.

Rogers G, Alper E, Brunelle D, Federico F, et al. Reconciling medications at admission: Safe practice recommendations and implementation strategies. Joint Commission Journal on Quality and Patient Safety. 2006 Jan;32(1):37-50.

This article describes a report on a statewide patient safety initiative to reduce medication errors by three Massachusetts medical agencies. The project resulted in 20 percent of enrolled organizations spreading significant changes in the area of medication reconciliation throughout their organizations. 

Full text available! Click view article below.

Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. Journal of the American Medical Association. Jul 1995;274(1):29-34.

This article describes a study which intended to assess incidence and preventability of adverse drug events (ADEs) and potential ADEs. The study concluded that adverse drug events were common and often preventable; serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. Prevention strategies should target both stages of the drug delivery process.

Federico F. Reconciling doses. Agency for Heathcare Research and Quality Web M&M [serial online]. November 2005.

This article presents a case and commentary with the following objectives: list the steps involved in medication reconciliation; describe the role of each of the stakeholders in medication reconciliation; and discuss how medication reconciliation decreases the opportunity for medication errors and harm.

Full text available! Click view article below.

Pronovost P, Weast B, Schwarz M, et al. Medication reconciliation: A practical tool to reduce the risk of medication errors. Journal of Critical Care. 2003;18(4):201-205.

This article discusses a study to reduce medication errors in patient's discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey, initiated within 24 hours of ICU admission and completed on discharge, was implemented as part of the medication reconciliation process. Use of the survey resulted in a dramatic drop in medications errors for patients discharged from an ICU.

Bond CA, Raehl CL. Clinical and economic outcomes of pharmacist-managed aminoglycoside or vancomycin therapy. American Journal of Health Systems Pharmacy. Aug 2005;62(15):1596-1605.

This articles describes a study that explored the associations between pharmacist-managed aminoglycoside or vancomycin therapy for hospitalized Medicare patients who had diagnoses indicating probable treatment with these antibiotics and the major health care outcomes of death rate, length of stay, Medicare charges, hearing loss, and renal impairment.