Wilson K, Sullivan M. Preventing medication errors with smart infusion technology. American Journal of Health-System Pharmacy. 2004 Jan 15;61(2):177-183.

This study discusses how pharmacists can identify high-risk areas and drugs that require special attention in error prevention efforts. It draws a particular focus to IV medication error prevention. 

Poon EG, Blumenthal D, Jaggi T, Honour MM, Bates DW, Kaushal R. Overcoming barriers to adopting and implementing computerized physician order entry systems in US hospitals. Health Affairs. 2004;23(4):184-190.

In this policy article, the authors attempt to answer the question of why only ten to fifteen percent of US hospitals use computerized physician order entry (CPOE) systems. Their interviews with senior management at 26 US hospitals reveal some of the barriers and potential solutions.

Leape LL, Kabcenell A, Berwick DM, Roessner J
Boston, Massachusetts, USA: Institute for Healthcare Improvement; 1998

**NOTE: This Breakthrough Series Guide was published in 1998 and has NOT been updated. Please be advised that much of the clinical content may be out of date.**        Institute for Healthcare Improvement (IHI) Breakthrough Series Guides are based on the real-life experiences of health care organizations that have made dramatic changes while participating in IHI Breakthrough Series Collaboratives. Each Guide contains a synopsis of a Collaborative’s goals and results, the model for accelerating improvement, change concepts that Collaborative participants used successfully, additional resources, key contacts, and a bibliography. This Guide is based on the 1996–97 Collaborative on Reducing Adverse Drug Events.

Gulseth MP, Meisel S, Meisel M. Increasing the safety of analgesia use in a community hospital. American Journal of Health-System Pharmacy. 1 Jun 2004;61:1143-1146.

Two sentinel events involving opioid-induced respiratory depression led to the formation of a multidisciplinary team that was able to achieve a 75 percent reduction in cases of severe respiratory depression due to opioid analgesics. This study shows that having a pain management team (pharmacist, CNS, anesthesiologist) monitor naloxone use on surgical floors increases the safety of opioid analgesia use while still maintaining analgesic efficacy.

Kohn LT, Corrigan JM, Donaldson MS, eds. (Committee on Quality of Health Care in America, Institute of Medicine)
Washington, DC, USA: National Academies Press; 1999

This report lays out a comprehensive strategy to reduce medical errors for government, industry, consumers, and health care providers, and it calls on the United States Congress to create a national patient safety center to develop the new tools and systems needed to address persistent problems. Each chapter of the report contains a reference list, allowing the reader to select additional material in specific areas of interest.

Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, Tizzard A. How to investigate and analyse clinical incidents: Clinical risk unit and association of litigation and risk management protocol. British Medical Journal. 2000 Mar 18;320(7237):777-781.

Developed by the Clinical Risk Unit and the Association of Litigation and Risk Management in the UK, this approach adapted research methods to produce a protocol for the investigation and analysis of serious incidents for use by risk managers and others trained in incident analysis. The authors point out that analyses of clinical incidents should focus less on individuals and more on organizational factors, and that organizational analyses lead directly to strategies for enhancing patient safety.

Meisel S, Sershon L, White D. Reducing adverse drug events and medication errors using rapid cycle improvement. Quality Management in Healthcare. 1998;6(4):15-28.

This article explains Fairview Health Services' (Edina, Minnesota, USA) work and committment within an IHI Collaborative on the topic of patient safety, particularly the area of medication errors. 

Doolan DF, Bates DW. Computerized physician order entry systems in hospitals: Mandates and incentives. Health Affairs. July/Aug 2002;21(4):180-188.

In this article, the authors discuss computerized physician order entry as well as some roadblocks impeding further spread of the technology.  The article also discusses some strategies to improve the dissemination of the technology throughout health care.

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Columbia Accident Investigation Board. The accident's organizational causes. Report Volume 1, Chapter 7. National Aeronautics and Space Administration. August 2003; 177-194.

According to this report of the Columbia Accident Investigation Board, the causes of the Columbia space shuttle accident are "rooted in the Space Shuttle Program's history and culture." Chapter 7 of the report specifically discusses the issues in NASA's safety culture: "NASA's organizational culture and structure had as much to do with this accident as the External Tank foam."

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Barach P, Berwick D. Patient Safety and the reliability of health care systems. Annals of Internal Medicine. 2003;138(12):997-998.

In this editorial that launches a series on patient safety in Annals of Internal Medicine, the authors reflect on the "ecologic metaphors" as a framework for understanding patient safety, and the educational implications of this new understanding of the problem.