Medication Safety Evidence Table

AORN Guideline for Medication Safety
Evidence Table
CONSENSUS SCORE
REFERENCE #
SAMPLE SIZE/ CONTROL/ OUTCOME

CITATION EVIDENCE TYPE INTERVENTION(S) CONCLUSION(S)
POPULATION COMPARISON MEASURE(S)
1 Boeker EB, de Boer M, Kiewiet JJS, Lie- Systematic Review w/ 6 studies n/a n/a Adverse drug events. Adverse drug events occur in a high proportion of IIIA
A-Huen L, Dijkgraaf MGW, Meta-Analysis surgical patients but less frequently than nonsurgical
Boermeester MA. Occurrence and patients. Of these events many are considered to be
preventability of adverse drug events preventable. The events were found to occur in all types
in surgical patients: a systematic of procedures and during all phases of the medication
review of literature. BMC Health Serv process.
Res. 2013;13:364.
2 ASHP guidelines on preventing Guideline n/a n/a n/a n/a Guidelines to assist with the prevention of medication IVC
medication errors in hospitals. Am J errors.
Hosp Pharm. 1993;50(2):305-314.
3 Hicks RW, Wanzer L, Goeckner B. Expert Opinion n/a n/a n/a n/a The medication use process is very different in the VB
Perioperative pharmacology: a perioperative environment.
framework for perioperative
medication safety. AORN J.
2011;93(1):136-142.
4 Seidling HM, Stutzle M, Hoppe-Tichy Qualitative 20 international n/a n/a Medication prescribing A multidisciplinary medication safety team should IIIB
T, et al. Best practice strategies to medication experts and administration manage the medication process, computerized order
safeguard drug prescribing and drug processes entry system should be used, and medication
administration: an anthology of reconciliation should be performed.
expert views and opinions. Int J Clin
Pharm. 2016;38(2):362-373.
5 Adhikari R, Tocher J, Smith P, Qualitative 20 nurses,3 pharmacists, 3 n/a n/a Medication A multidisciplinary approach should be used to improve IIIB
Corcoran J, MacArthur J. A multi- pharmacy technicians, 8 management practices. medication safety and nurses need more pharmacology
disciplinary approach to medication doctors in 2 wards in 2 education.
safety and the implication for nursing Scottish hospital hospitals
education and practice. Nurse Educ
Today. 2014;34(2):185-190.
Copyright © AORN, Inc. All rights reserved. Page 1 of 68

Evidence Table
CONSENSUS SCORE
REFERENCE #

6 Cousins DH, Gerrett D, Warner B. A Nonexperimental 526,186 medication n/a n/a Medication errors Medication errors occur at all phases of the medication IIIB
review of medication incidents incident reports. administration process and a multidisciplinary team
reported to the national reporting and should be created to assist with decreasing the errors
learning system in England and Wales and the information needs to be shared with those
over 6 years (2005-2010). Br J Clin involved.
Pharmacol. 2012;74(4):597-604.
7 Härkänen M, Turunen H, Vehviläinen- Nonexperimental Medication errors found n/a n/a Presence of The three methods for error detection revealed different IIIA
Julkunen K. Differences between on 671 incident reports, medication errors information on the medication errors, therefore the
methods of detecting medication 153 global trigger tool different methods should be combined. The researchers
errors: a secondary analysis of results, and 235 also recommend advanced multi-professional
medication administration errors observations. collaboration, effective communication, adequate skills,
using incident reports, the global distraction-free work environments, and implementation
trigger tool method, and of more systematic medication use processes.
observations. J Patient Saf. March 24,
2016. Epub ahead of print.
8 Grou Volpe CR, Moura Pinho DL, Nonexperimental 484 medication n/a n/a Medication errors Interdisciplinary committees should be established to IIIB
Morato Stival M, De Oliveira administrations help alleviate medication errors and nurses need
Karnikowski MG. Medication errors in additional periodic education on medication
a public hospital in Brazil. Br J Nurs. administration.
2014;23(11):552-559.
9 Goldspiel B, Hoffman JM, Griffith NL, Guideline n/a n/a n/a n/a Evidence based guideline for preventing medication IVC
et al. ASHP guidelines on preventing errors in patients receiving chemotherapy and
medication errors with chemotherapy biotherapy.
and biotherapy. Am J Health Syst
Pharm. 2015;72(8):e6-e35.
10 Anderson P, Townsend T. Preventing Expert Opinion n/a n/a n/a n/a Medication prevention strategies include performing an VC
high alert medication errors in independent double check, creating a multidisciplinary
hospital patients. Am Nurse Today. pharmacy and therapeutics committee, using a visual
2015;10(5):18-23. cue to decrease interruptions during medication
administration, separated storage for sound-alike and
look-alike medications, use tall man lettering for look-
alike, sound alike or confusing named medications.
11 ASHP guidelines: minimum standard Guideline n/a n/a n/a n/a Consensus guideline for pharmacies. IVC
for pharmacies in hospitals. Am J
Health Syst Pharm. 2013;70(18):1619-
1630.

Evidence Table
CONSENSUS SCORE
REFERENCE #

12 Sanchez SH, Sethi SS, Santos SL, Qualitative 13 people responsible for n/a n/a What is needed to A multidisciplinary team and education are needed to IIIB
Boockvar K. Implementing medication planning medication successfully implement implement a successful medication reconciliation
reconciliation from the planner’s reconciliation processes. a medication process.
perspective: a qualitative study. BMC reconciliation system.
Health Serv Res. 2014;14:290.
13 Mandrack M, Cohen MR, Featherling Expert Opinion n/a n/a n/a n/a Education should be provided regarding use of VB
J, et al. Nursing best practices using automated drug dispensing cabinets and a
automated dispensing cabinets: multidisciplinary medication task force should make
nurses’ key role in improving decisions regarding the automated drug dispensing
medication safety. Medsurg Nurs. system.
2012;21(3):134-144.
14 Buxton JA, Babbitt R, Clegg CA, et al. Guideline n/a n/a n/a n/a Guidelines for the ambulatory care pharmacy. IVB
ASHP guidelines: minimum standard
for ambulatory care pharmacy
practice. Am J Health Syst Pharm.
2015;72(14):1221-1236.
15 Zhao RY, He XW, Shan YM, Zhu LL, Organizational In 2010-5,309 patients; n/a n/a Adverse drug events Multidisciplinary collaboration resulted in a decrease in VA
Zhou Q. A stewardship intervention Experience 2011-6,315 patients; 2012- medication errors related to insulin use.
program for safe medication 6,974 patients; 2013-7,375
management and use of antidiabetic patients.
drugs. Clin Interv Aging. 2015;10:1201-
1212.
16 Merry AF, Shipp DH, Lowinger JS. The Expert Opinion n/a n/a n/a n/a Medication syringes and containers should be labeled VB
contribution of labelling to safe consistently, with tall man letters for look-alike
medication administration in medications, also tubing should be labeled.
anaesthetic practice. Best Pract
Res.Clin Anaesthesiol. 2011;25(2):145-
159.
17 May SK, Park S. Risk factors and Literature Review n/a n/a n/a n/a Multiple interventions are recommended based upon VB
strategies for prevention of the literature reviewed for improving medication safety.
medication errors in patients with
subarachnoid hemorrhage. Hosp
Pharm. 2013;48(Suppl 5):S10-S20.
18 Mankes RF, Silver CD. Quantitative Nonexperimental Medications wasted at two n/a n/a Numbers of Education on environmental impact of disposed IIIB
study of controlled substance bedside facilities. medications wasted medications may help to change prescribing practices.
wasting, disposal and evaluation of Multidisciplinary team should evaluate medication
potential ecologic effects. Sci Total disposal practices.
Environ. 2013;444:298-310.

Evidence Table
CONSENSUS SCORE
REFERENCE #

19 ASHP guidelines on handling Guideline n/a n/a n/a n/a The recommendations address the precautions to be IVC
hazardous drugs. Am J Health Syst taken when handling hazardous medications.
Pharm. 2006;63(12):1172-1193.
20 De Oliveira GSJ, Theilken LS, McCarthy Expert Opinion n/a n/a n/a n/a Action plans for handling medication shortages should VB
RJ. Shortage of perioperative drugs: be in place.
implications for anesthesia practice
and patient safety. Anesth Analg.
2011;113(6):1429-1435.
21 Golembiewski J. Drug shortages in the Expert Opinion n/a n/a n/a n/a The facility should have an action plan to handle VB
perioperative setting: causes, impact, medication shortages.
and strategies. J Perianesth Nurs.
2012;27(4):286-292.
22 Engels MJ, Ciarkowski SL. Nursing, Nonexperimental 465 nurses, 136 pharmacy n/a n/a Knowledge, Ongoing education on high-alert medications and the IIIA
pharmacy, and prescriber knowledge personnel, 177 prescribers. experience, and applicable risk reduction strategies is necessary to
and perceptions of high-alert perceptions regarding decrease knowledge gaps and to ensure individuals
medications in a large, academic high-alert medications. accept accountability in the medication use process.
medical hospital. Hosp Pharm.
2015;50(4):287-295.
23 Centers for Medicare & Medicaid Regulatory n/a n/a n/a n/a Regulatory requirements for verbal orders, n/a
Services(CMS), DHHS. Medicare and compounding, and securing medications.
Medicaid programs; hospital
conditions of participation:
requirements for history and physical
examinations; authentication of
verbal orders; securing medications;
and postanesthesia evaluations. Final
rule. Fed Regist. 2006;71(227):68671-
68695.
24 Cohen MR, Smetzer JL. No unlabeled Case Report n/a n/a n/a n/a Label medications on the sterile field, use Tall man VC
containers anywhere, ever! Where letters on labels, put medications on sterile field as close
did this come from? Hosp Pharm. to time of use a s possible, verify medication when
2015;50(3):185-188. delivering to sterile field, discard all unlabeled solutions
on sterile field.
25 Erbe B. Safe medication Organizational 15 cases with blank labels Introductions of preprinted Labeling before and n/a Fewer inappropriate abbreviations were used with the VB
administration in the operating room. Experience and 15 cases with labels. after introduction of preprinted labels compared to handwritten labels.
Tar Heel Nurse. 2011;73(1):10-13. preprinted labels. preprinted labels.

Evidence Table
CONSENSUS SCORE
REFERENCE #

26 Bonkowski J, Carnes C, Melucci J, et Quasi-experimental 996 medication Implementation of a Before implementation Percentage of Emergency department drug errors were reduced after IIB
al. Effect of barcode-assisted administrations before barcode-assisted of a barcode-assisted medication errors. the introduction of the barcode-assisted medication
medication administration on implementation, 982 after medication administration medication administration system.
emergency department medication implementation in an system. administration system.
errors. Acad Emerg Med. emergency department at
2013;20(8):801-806. an academic medical
center.
27 Bonkowski J, Weber RJ, Melucci J, Quasi-experimental 936 medication Implementation of a Before implementation Medication errors Solid organ transplant unit drug errors were reduced IIB
Pesavento T, Henry M, Moffatt-Bruce administrations before barcode-assisted of a barcode-assisted after the introduction of the barcode-assisted
S. Improving medication implementation, 976 after medication administration medication medication administration system.
administration safety in solid organ implementation in a solid system. administration system.
transplant patients through barcode- organ transplant unit at an
assisted medication administration. academic medical center.
Am J Med Qual. 2014;29(3):236-241.
28 Sethuraman U, Kannikeswaran N, Nonexperimental 7,268 orders before, 7,292 Electronic prescription Paper-based order Order entry errors. Prescription errors decreased with the use of IIIB
Murray KP, Zidan MA, Chamberlain orders after. order entry system entry system. computerized prescriber order entry system.
JM. Prescription errors before and
after introduction of electronic
medication alert system in a pediatric
emergency department. Acad Emerg
Med. 2015;22(6):714-719.
29 Ching JM, Williams BL, Idemoto LM, Quasi-experimental Patients admitted from Implementation of a No barcode medication Medication errors Medication errors decreased after implementation of a IIB
Blackmore CC. Using lean 2010 -2012. barcode medication administration system. barcode medication administration system.
“automation with a human touch” to administration system.
improve medication safety: a step
closer to the “perfect dose.” Jt Comm
J Qual Patient Saf. 2014;40(8):341-
350.
30 Armada ER, Villamanan E, Lopez-de- Nonexperimental 158 treatment order using Computerized prescriber Paper based ordering Medication errors Medication errors decreased after implementation of a IIIB
Sa E, et al. Computerized physician paper entry, 142 order entry system computerized prescriber order entry system, education
order entry in the cardiac intensive computerized entry. should be provided on the use of the system, and errors
care unit: effects on prescription should be reviewed.
errors and workflow conditions. J Crit
Care. 2014;29(2):188-193.

Evidence Table
CONSENSUS SCORE
REFERENCE #

31 Allison GM, Weigel B, Holcroft C. Nonexperimental 100 patients pre and post n/a n/a Medication errors Medication errors decreased with the use of an IIIB
Does electronic medication implementation. electronic medication reconciliation tool.
reconciliation at hospital discharge
decrease prescription medication
errors? Int J Health Care Qual Assur.
2015;28(6):564-573.
32 Charles K, Cannon M, Hall R, Systematic review n/a n/a n/a n/a The use of computerized provider order entry systems IIB
Coustasse A. Can utilizing a helps to decrease medication errors.
computerized provider order entry
(CPOE) system prevent hospital
medical errors and adverse drug
events? Perspect Health Inf Manag.
2014;11:1b.
33 Connor AJ, Hutton P, Severn P, Masri Qualitative 100 prescriptions from n/a n/a Presence of all Computerized provider order entry should be used or at IIIB
I. Electronic prescribing and each day surgery, components of the least use paper forms with prompts.
prescription design in ophthalmic ophthalmology, and 50 prescriptions.
practice. Eur J Ophthalmol. discharge prescriptions.
2011;21(5):644-648.
34 Fischer JR. The impact of health care Literature Review n/a n/a n/a n/a The use of electronic medication administration records, VC
technology on medication safety. S D barcode technology, computerized provider order entry,
Med. 2014;67(7):279-280. and clinical decision support systems decreased the
rates of medication errors but the reduction in the rate
of errors is not linked to the degree or amount of patient
harm and further research is needed in this area.
35 Green RA, Hripcsak G, Salmasian H, et Quasi-experimental 3,457,342 electronic Implementation of a No computerized Wrong-patient orders Wrong-patient medication errors decreased with the IIB
al. Intercepting wrong-patient orders orders computerized order entry provider order entry implementation of a computerized provider order entry
in a computerized provider order system. system. system.
entry system. Ann Emerg Med.
2015;65(6):679-686.
36 Henneman PL, Marquard JL, Fisher DL, Nonexperimental 25 emergency room nurses n/a n/a Scenario based Medication errors are decreased, but not eliminated by IIIB
et al. Bar-code verification: reducing identification of the use of a bar-code system.
but not eliminating medication errors. medication errors.
J Nurs Adm. 2012;42(12):562-566.

Evidence Table
CONSENSUS SCORE
REFERENCE #

37 Hernandez F, Majoul E, Montes- Quasi-experimental 1,593 prescriptions pre, Implementation of an Paper based ordering Medication errors The number of medication errors decreased following IIB
Palacios C, et al. An observational 1,388 prescriptions post. computerized prescriber system. the implementation of a computerized prescriber order
study of the impact of a computerized order entry system. entry system.
physician order entry system on the
rate of medication errors in an
orthopaedic surgery unit. PLoS One.
2015;10(7):e0134101.
38 Hassink JJM, Jansen MMPM, Helmons Literature Review n/a n/a n/a n/a Barcode-assisted medication administration systems VB
PJ. Effects of bar code-assisted help to reduce medication errors.
medication administration (BCMA) on
frequency, type and severity of
medication administration errors: a
review of the literature. Eur J Hosp
Pharm Sci Pract. 2012;19(5):489-494.
39 Khammarnia M, Kassani A, Eslahi M. Systematic Review w/ 14 articles n/a n/a Effectiveness of Use of an unique patient identification barcode system IIA
The efficacy of patients’ wristband bar- Meta-Analysis wristband bar-code will help to reduce medication errors.
code on prevention of medical errors: medication scanning.
a meta-analysis study. Appl Clin
Inform. 2015;6(4):716-727.
40 Leung AA, Schiff G, Keohane C, et al. Quasi-experimental 775 patients pre, 815 Application of Clinical No clinical decision Rates of preventable, Computerized physician order entry with advanced IIB
Impact of vendor computerized patients post. decision support. support overall , and potential clinical decision support can reduce the number of
physician order entry on patients with adverse drug events. preventable adverse drug events.
renal impairment in community
hospitals. J Hosp Med. 2013;8(10):545-
552.
41 Manias E, Kinney S, Cranswick N, Systematic Review w/ n/a n/a n/a n/a The use of computerized prescriber order entry with IIIA
Williams A, Borrott N. Interventions Meta-Analysis computerized decision support decreased medication
to reduce medication errors in error rates in a pediatric ICU.
pediatric intensive care. Ann
Pharmacother. 2014;48(10):1313-
1331.

Evidence Table
CONSENSUS SCORE
REFERENCE #

42 Nuckols TK, Smith-Spangler C, Morton Systematic Review w/ n/a n/a n/a n/a The use of computerized provider order entry systems IIIA
SC, et al. The effectiveness of Meta-Analysis reduces medication errors.
computerized order entry at reducing
preventable adverse drug events and
medication errors in hospital settings:
a systematic review and meta-
analysis. Syst Rev. 2014;3:56.
43 Roberts DL, Noble B, Wright MJ, Quasi-experimental Patients admitted to Application of n/a Medication errors The use of computerized prescriber order entry IIA
Nelson EA, Shaft JD, Rakela J. Impact facility from November computerized order entry decreased medication error rates.
of computerized provider order entry 6,2006 to May 7,2007. No system.
on hospital medication errors. J Clin sample size provided.
Outcomes Manag. 2013;20(3):109-
115.
44 Sanchez Cuervo M, Rojo Sanchis A, Quasi-experimental 150 prescription pre and 5 years after implementing Before implementing Medication errors Medication errors continued to be less 5 years after IIA
Pueyo Lopez C, Gomez De Salazar post. a computerized provider the system. implementing a computerized provider order entry
Lopez De Silanes E, Gramage Caro T, order entry system. system.
Bermejo Vicedo T. The impact of a
computerized physician order entry
system on medical errors with
antineoplastic drugs 5 years after its
implementation. J Clin Pharm Ther.
2015;40(5):550-554.
45 Shawahna R, Rahman N, Ahmad M, Quasi-experimental 13,328 prescriptions pre, Electronic prescribing Paper prescribing Prescribing errors Use of electronic prescribing decreased the number of IIB
Debray M, Yliperttula M, Decleves X. 14,064 prescriptions post. prescribing errors.
Electronic prescribing reduces
prescribing error in public hospitals. J
Clin Nurs. 2011;20(21-22):3233-3245.
46 Truitt E, Thompson R, Blazey-Martin Quasi-experimental 397 pre-implementation Implementation of a Medication errors pre- Number of adverse Adverse drug events and transcription errors decreased IIB
D, NiSai D, Salem D. Effect of the errors and 378 post- electronic medication and post- drug events and in the five months after implementation of bar code
implementation of barcode implementation errors. administration record and implementation of an severity level of technology. The mean severity level of the
technology and an electronic Errors used occurred barcode medication electronic medication administration errors. administration errors also decreased.
medication administration record on within 5 months before or administration. administration record
adverse drug events. Hosp Pharm. after implementation. and barcode
2016;51(6):474-483. medication
administration.

Evidence Table
CONSENSUS SCORE
REFERENCE #

47 Westbrook JI, Li L, Georgiou A, Nonexperimental 129 nurses and physicians n/a n/a Medication errors Medication errors were decreased when an electronic IIIB
Paoloni R, Cullen J. Impact of an medication management system was introduced and
electronic medication management patient care time was not changed.
system on hospital doctors’ and
nurses’ work: a controlled pre-post,
time and motion study. J Am Med
Inform Assoc. 2013;20(6):1150-1158.
48 Jozefczyk KG, Kennedy WK, Lin MJ, et Quasi-experimental 500 orders in both the pre Implementation of an Pre-implementation Number of The opportunities for error decreased after the IIB
al. Computerized prescriber order and post implementation computerized prescriber opportunities for error. implementation of a computerized prescriber order
entry and opportunities for groups. order entry system. entry system.
medication errors: comparison to
tradition paper-based order entry. J
Pharm Pract. 2013;26(4):434-437.
49 Buus A, Nyvang L, Heiden S, Pape- Qualitative Observation phase: Three n/a n/a Impact of tablet Use of technology has the potential to improve patient IIIB
Haugaard L. Quality assurance and nurses for two days of computers on safety but needs continuous updates to remain effective.
effectiveness of the medication medication medication dispensing
process through tablet computers? administrations. and administration.
Stud Health Technol Inform. Structured workshop
2012;180:348-352. phase: seven health care
professionals. Qualitative
interviews: two nurses and
two experts.
50 McComas J, Riingen M, Chae Kim S. Nonexperimental 78 medication Implementation of a Manual documentation Medication errors Medication errors decreased after implementation of IIIB
Impact of an electronic medication administration activities electronic medication the electronic medication administration record.
administration record on medication pre, 78 medication administration record
administration efficiency and errors. administration activities
Comput Inform Nurs. 2014;32(12):589- post
595.
51 Seibert HH, Maddox RR, Flynn EA, Quasi-experimental Facility 1: 2092 medication Implementation of a Pre and post Medication errors The medication accuracy rate improved significantly with IIA
Williams CK. Effect of barcode administrations prior to barcode medication implementation of a the use of a barcode-assisted medication administration
technology with electronic and 1577 administrations administration system. barcode-assisted system.
medication administration record on after. Facility 2: 2061 medication
medication accuracy rates. Am J medication administration system.
Health Syst Pharm. 2014;71(3):209- administrations before and
218. 773 after. Multiple units
were studied at both
facilities.

Evidence Table
CONSENSUS SCORE
REFERENCE #

52 Dwibedi N, Sansgiry SS, Frost CP, et al. Nonexperimental 101 paper-based n/a Pre and post Medication During bar code medication administration the time IIIB
Bedside barcode technology: impact medication implementation of a administration time spent by nurses on administering medications and
on medication administration tasks in administrations and 151 bedside barcode documenting medications was significantly reduced, and
an intensive care unit. Hosp Pharm. bedside barcode medication the time conversing with patients was increased.
2012;47(5):360-366. medication administration system.
administrations in an ICU
setting.
53 Abbass I, Mhatre S, Sansgiry SS, Nonexperimental 563 paper-based orders, n/a n/a Medication errors and Use of a computerized prescribing system reduced errors IIIA
Tipton J, Frost C. Impact and 547 computer based turnaround time. and medication turnaround times.
determinants of commercial orders
computerized prescriber order entry
on the medication administration
process. Hosp Pharm. 2011;46(5):341-
348.
54 Stroud D. Preventing medication Organizational N/a n/a n/a n/a The implementation of computerized medication VC
administration errors: lockable, Experience administration carts decreased the amount of
computerized medication medications administered late and resulted in reduced
administration carts help hospitals costs related to wasted medications.
avoid errors and reduce costs. Health
Manag Technol. 2013;34(11):18-19.
55 Aziz MT, Ur-Rehman T, Qureshi S, Nonexperimental 5514 and 3765 Computerized ordering Paper based ordering Medication errors Medication errors decreased after implementation of a IIIB
Bukhari NI. Reduction in chemotherapy protocol system system computerized prescriber order entry system and it also
chemotherapy order errors with orders. assisted with decrease in severity of errors,
computerised physician order entry improvements in dispensing and prescribing times and a
and clinical decision support systems. reduction in costs.
HIM J. 2015;44(3):13-22.
56 Maat B, Rademaker CMA, Oostveen Quasi-experimental Seven physicians Initiation of a No computerized Length of prescribing The time taken to prescribe insulin in enteral and IIB
MI, Krediet TG, Egberts TCG, Bollen computerized physician physician order entry time parenteral nutrition was less when using the
CW. The effect of a computerized order entry system system computerized prescribing system.
prescribing and calculating system on
hypo- and hyperglycemias and on
prescribing time efficiency in neonatal
intensive care patients. JPEN J
Parenter Enteral Nutr. 2013;37(1):85-
91.
57 Hollister DJ, Messenger A. Organizational 184,474 prescriptions pre, Implementation of a n/a Medication errors, The use of a computerized prescriber order entry system VB
Implementation of computerized Experience 240,456 post. computerized prescriber verification time and reduced the number of medication errors, shortened
physician order entry at a community order entry system. number of illegible pharmacy verification time and improved identification
hospital. Conn Med. 2011;75(4):227- signatures. of ordering physicians.
233.

Evidence Table
CONSENSUS SCORE
REFERENCE #

58 Morley C, McLeod E, McKenzie D, et Literature Review n/a n/a n/a n/a Measures to prevent medication errors include VB
al. Reducing dose omission of education, clear multidisciplinary communication
prescribed medications in the hospital between all parties involved in the medication process,
setting: a narrative review. Drugs Ther use of computerized order entry, and changing
Perspect. 2016;32(5):203-208. pharmacy processes to be certain medication is
available.
59 Hartel MJ, Staub LP, Roder C, Eggli S. Nonexperimental 1,934 prescriptions n/a n/a Legibility of A computerized order entry system should be used IIIB
High incidence of medication prescription and instead of hand written prescription because many hand
documentation errors in a Swiss documentation / written contain errors and are not legible.
university hospital due to the transcription errors.
handwritten prescription process.
BMC Health Serv Res. 2011;11:199.
60 Albarrak AI, Al Rashidi EA, Fatani RK, RCT 199 handwritten and 199 Computerized prescribing Handwritten Incomplete or illegible The use of computerized provider order entry systems IB
Al Ageel SI, Mohammed R. computerized system prescribing prescriptions resulted in a decrease in illegible and incomplete
Assessment of legibility and prescriptions prescriptions.
completeness of handwritten and
electronic prescriptions. Saudi Pharm
J. 2014;22(6):522-527.
61 Abramson EL, Barron Y, Quaresimo J, Quasi-experimental 2,432 prescriptions pre, Implementation of No computerized Prescribing errors Use of computerized physician order entry systems IIB
Kaushal R. Electronic prescribing 2,079 prescriptions post. computerized prescriber prescriber order entry decreases ambulatory prescribing errors.
within an electronic health record order entry system. system.
reduces ambulatory prescribing
errors. Jt Comm J Qual Patient Saf.
2011;37(10):470-478.
62 Meisenberg BR, Wright RR, Brady- Organizational 2.216 handwritten, 2,480 n/a n/a n/a Pre-printed orders contained fewer errors than VA
Copertino CJ. Reduction in Experience preprinted, 5,142 handwritten orders and orders entered on a
chemotherapy order errors with computerized orders. computerized prescriber order entry system contained
computerized physician order entry. J even fewer orders.
Oncol Pract. 2014;10(1):e5-e9.
63 Al-Rowibah FA, Younis MZ, Parkash J. Nonexperimental 93 physicians n/a n/a Medication error The physicians who responded to the survey believed IIIB
The impact of computerized physician the computerized order entry decreased the number of
order entry on medication errors and medication errors when compared to hand-written
adverse drug events. J Health Care prescriptions.
Finance. 2013;40(1):93-102.

Evidence Table
CONSENSUS SCORE
REFERENCE #

64 Fanning L, Jones N, Manias E. Impact Nonexperimental 1139 medication selections Implementation of Use of medication Medication Use of automated dispensing cabinets has been shown IIIB
of automated dispensing cabinets on and preparations pre, 864 automated drug dispensing storage room preparation and to decrease the number of medication selection and
medication selection and preparation post implementation system selection errors preparation errors.
error rates in an emergency
department: a prospective and direct
observational before-and-after study.
J Eval Clin Pract. 2016;22(2):156-163.
65 Cochran GL, Barrett RS, Horn SD. Nonexperimental 2955 onsite pharmacist, n/a n/a Medication error rates Medication errors are reduced with the use of a barcode IIIA
Comparison of medication safety 3031 tele pharmacist. medication system and with the use of an on site
systems in critical access hospitals: pharmacist.
combined analysis of two studies. Am
J Health Syst Pharm.
2016;73(15):1167-1173.
66 Tsao NW, Lo C, Babich M, Shah K, Systematic review n/a n/a n/a n/a Automated drug dispensing units may decrease IIIB
Bansback NJ. Decentralized medication errors and increase efficiency.
automated dispensing devices:
systematic review of clinical and
economic impacts in hospitals. Can J
Hosp Pharm. 2014;67(2):138-148.
67 Turchin A, Shubina M, Goldberg S. Nonexperimental 573 patients on warfarin n/a n/a Presence of an internal Consequences of errors using CPOE may not be obvious IIIB
Unexpected effects of unintended with hemorrhage, 1719 discrepancy in the and internal discrepancies are an error that occurs only
consequences: EMR prescription controls. electronic warfarin with CPOE.
discrepancies and hemorrhage in prescription.
patients on warfarin. AMIA Annu
Symp Proc. 2011;2011:1412-1417.
68 Sparnon E. Spotlight on electronic Nonexperimental 324 reports n/a n/a Cause of error Failure to change a default value was the most common IIIB
health record errors: errors related to reported cause of error.
the use of default values. Penn
Patient Saf Advis. 2013;10(3):92-95.
69 Rodriguez-Gonzalez CG, Herranz- Nonexperimental 2314 medication n/a n/a Frequency of Medication errors continue to exist in units using IIIB
Alonso A, Martin-Barbero ML, et al. administrations medication errors with computerized order entry systems and nurses were
Prevalence of medication the use of a lacking knowledge about medications.
administration errors in two medical computerized order
units with automated prescription entry system.
and dispensing. J Am Med Inform
Assoc. 2012;19(1):72-78.

Evidence Table
CONSENSUS SCORE
REFERENCE #

70 Stultz JS, Nahata MC. Preventability of Nonexperimental 1649 medication error n/a n/a Phase error occurred Some medication errors that occur during use of an IIIB
voluntarily reported or trigger tool- reports and if preventable by electronic medication ordering system may be
identified medication errors in a electronic medication preventable by correct use of the information
pediatric institution by information ordering system. technology and others are not.
technology: a retrospective cohort
study. Drug Saf. 2015;38(7):661-670.
71 Wetterneck TB, Walker JM, Blosky Nonexperimental 4147 patient days pre, Implementation of a No computerized order Duplicate medication Duplicate medication errors increased after IIIB
MA, et al. Factors contributing to an 4013 patient days post computerized order entry entry system. orders implementation of a computerized order entry system.
increase in duplicate medication system.
order errors after CPOE
implementation. J Am Med Inform
Assoc. 2011;18(6):774-782.
72 Van Der Sijs H, Rootjes I, Aarts J. The Qualitative A resident, medical n/a n/a Workarounds Work arounds exist in both paper and electronic IIIB
shift in workarounds upon specialist, senior nurse, prescribing systems.
implementation of computerized second nurse, and
physician order entry. Stud Health pharmacist on two units
Technol Inform. 2011;169:290-294. one with electronic
ordering and one with
paper ordering.
73 Joy A, Davis J, Cardona J. Effect of Organizational 13,791 medication orders Implementation of Paper based n/a Use of a computerized prescribing system reduced VA
computerized provider order entry on Experience pre, 35,029 medication computerized prescription prescription ordering. medication errors.
rate of medication errors in a orders post. system.
community hospital setting. Hosp
Pharm. 2012;47(9):693-699.
74 Nelson CE, Selbst SM. Electronic Nonexperimental 350 prescriptions n/a n/a Medication errors Medication errors including clinically significant errors IIIA
prescription writing errors in the continued after the implementation of computerized
pediatric emergency department. prescription order entry.
Pediatr Emerg Care. 2015;31(5):368-
372.
75 Schwartzberg D, Ivanovic S, Patel S, Quasi-experimental 1,280,606 orders pre and Electronic prescription Paper-based order Order entry errors. Medication order errors continue after implementation IIB
Burjonrappa SC. We thought we 2,089,632 orders post order entry system entry system. of an electronic order entry system.
would be perfect: medication errors implementation
before and after the initiation of
computerized physician order entry. J
Surg Res. 2015;198(1):108-114.

Evidence Table
CONSENSUS SCORE
REFERENCE #

76 Naunton M, Gardiner HR, Kyle G. Look- Case Report n/a n/a n/a n/a Case report describing a situation in which a prescriber VC
alike, sound-alike medication errors: a selected the wrong medication from a list of medications
novel case concerning a Slow-Na, both of which began with "Slow".
Slow-K prescribing error. Int Med
Case Rep J. 2015;8:51-53.
77 Cohen MR, Smetzer JL. ISMP Case Report n/a n/a n/a n/a Case report describing medication errors related to VC
medication error report selecting the wrong medication in a computerized
analysis—tretinoin confused with provider order entry system, name confusion, and
isotretinoin; death from intravenous medication given via the wrong route.
nimodipine; incorrect medication
names selected during order entry;
reduce Ambien dose in order sets;
confusion between levothyroxine and
liothyronine. Hosp Pharm.
2013;48(6):455-457.
78 Maat B, Au YS, Bollen CW, van Vught Nonexperimental 1577 cases, 1983 controls n/a n/a Frequency of clinical Prescribing errors continue to occur even after IIIA
AJ, Egberts TCG, Rademaker CMA. pharmacy implementation of a computerized prescriber order
Clinical pharmacy interventions in interventions. entry system especially when the name is inserted using
paediatric electronic prescriptions. free text.
Arch Dis Child. 2013;98(3):222-227.
79 Tully MP. Prescribing errors in Literature Review n/a n/a n/a n/a More research needs to occur using similar definitions, VB
hospital practice. Br J Clin Pharmacol. most errors are multifactorial, CPOE may decrease some
2012;74(4):668-675. errors but others are created.
80 Villamanan E, Larrubia Y, Ruano M, et Nonexperimental 85,857 prescriptions n/a n/a Medication errors Medication errors are decreased with the use of IIIB
al. Potential medication errors computerized prescriber order entry but there are new
associated with computer prescriber errors that are directly attributed to the computerized
order entry. Int J Clin Pharm. order entry system.
2013;35(4):577-583.
81 Warrick C, Naik H, Avis S, Fletcher P, Quasi-experimental 528 prescriptions pre, 216 Implementation of a No computerized Medication errors Electronic prescribing decreased some errors but IIB
Franklin BD, Inwald D. A clinical post phase 1, 278 post computerized prescriber prescriber order entry introduced some new types of errors.
information system reduces phase 2. order entry system. system.
medication errors in paediatric
intensive care. Intensive Care Med.
2011;37(4):691-694.

Evidence Table
CONSENSUS SCORE
REFERENCE #

82 Gimenes FRE, Marques TC, Teixeira Nonexperimental 1,425 situations of n/a n/a Discrepancy between The use of abbreviations lead to medications being IIIB
TCA, Mota MLS, Silva AE, Cassiani SH. disagreement between the the method the administered via the wrong route, even with the use of
Medication wrong-route way the medication was medication was an electronic order entry system that allows for the use
administrations in relation to medical administered and the administered and the of abbreviations and acronyms. The use of abbreviations
prescriptions. Rev Lat Am prescription. prescription. was related to the lack of knowledge about the
Enfermagem. 2011;19(1):11-17. ramifications of abbreviations use.
83 Redwood S, Rajakumar A, Hodson J, Nonexperimental 485 incidents n/a n/a Incidents related to New types of medication errors are created when IIIB
Coleman JJ. Does the implementation computerized order computerized prescriber order entry is implemented.
of an electronic prescribing system entry
create unintended medication errors?
A study of the sociotechnical context
through the analysis of reported
medication incidents. BMC Med
Inform Decis Mak. 2011;11:29.
84 Westbrook JI, Reckmann M, Li L, et al. Quasi-experimental 1,923 prescriptions pre, Implementation of a No computerized Medication errors Electronic prescribing decreased some errors but IIA
Effects of two commercial electronic 1,368 post . computerized prescriber prescriber order entry introduced some new types of errors.
prescribing systems on prescribing order entry system. system.
error rates in hospital in-patients: a
before and after study. PLoS Med.
2012;9(1):e1001164.
85 Hinojosa-Amaya JM, Rodríguez-Garcia Quasi-experimental 301 medical records pre, Implementation of an Paper based ordering Number of medication The number of medication errors decreased after IIA
FG, Yeverino-Castro SG, Sánchez- 300 medical records post. computerized prescriber system. errors and ranking on a implementation of a computerized prescriber order
Cárdenas M, Villarreal-Alarcón MÁ, order entry system. severity index. entry system but the severity of the errors increased.
Galarza-Delgado DÁ. Medication
errors: electronic vs. paper-based
prescribing. Experience at a tertiary
care university hospital. J Eval Clin
Pract. 2016;22(5):751-754.
86 Electronic prescribing: the risk of Literature Review n/a n/a n/a n/a Several types of medication errors have been reported VB
errors and adverse effects. Prescrire even with the use of computerized prescriber order
Int. 2016;25(167):24-27. entry systems, some of which did not exist prior to the
introduction of computerized order entry systems.
87 Leung AA, Keohane C, Amato M, et al. Quasi-experimental 1,000 medical records Implementation of a No computerized Adverse drug event The number of preventable adverse drug events IIB
Impact of vendor computerized before and 1,000 records computerized prescriber provider order entry decreased but the number of potential adverse drug
physician order entry in community after implementation. order entry system. system used. events actually increased.
hospitals. J Gen Intern Med.
2012;27(7):801-807.

Evidence Table
CONSENSUS SCORE
REFERENCE #

88 Hoonakker PLT, Carayon P, Walker Nonexperimental 267 nurses and providers n/a n/a Quality of Implementation of a computerized order entry system IIIB
JM, Brown RL, Cartmill RS. The effects communication has a negative effect on communication for the short
of computerized provider order entry term but it returns to normal in the long term.
implementation on communication in
intensive care units. Int J Med Inform.
2013;82(5):e107-e117.
89 Tschannen D, Talsma A, Reinemeyer Nonexperimental 50 observations from ICU, n/a n/a Alterations in workflow The nursing workflow pattern was altered when the IIIB
N, Belt C, Schoville R. Nursing 36 observations from computerized prescriber order entry system was
medication administration and Pediatrics. introduced which may lead to more medication errors.
workflow using computerized
physician order entry. Comput Inform
Nurs. 2011;29(7):401-410.
90 Samaranayake NR, Cheung DST, Lam Organizational 1,028 pre implementation. Implementation of a "Do No "Do Not Use" list Use of risky A "Do not use" abbreviation list is beneficial but VB
MPS, et al. The effectiveness of a “do Experience 1,134 Phase 1 post, 1,076 Not Use" abbreviation list abbreviations continual education on abbreviations is warranted.
not use” list and perceptions of Phase 2 post.
healthcare professionals on error-
prone abbreviations. Int J Clin Pharm.
2014;36(5):1000-1006.
91 Samaranayake NR, Dabare PRL, Nonexperimental 989 prescriptions n/a n/a Unapproved Several abbreviations identified as error prone were IIIB
Wanigatunge CA, Cheung BMY. The abbreviations. used in prescriptions and a "Do not use" list should be
pattern of abbreviation use in developed and education provided.
prescriptions: a way forward in
eliminating error-prone abbreviations
and standardisation of prescriptions.
Curr Drug Saf. 2014;9(1):34-42.
92 Flannery AH, Parli SE. Medication Expert Opinion n/a n/a n/a n/a The multidisciplinary team should review and approve VB
errors in cardiopulmonary arrest and drug references.
code-related situations. Am J Crit
Care. 2016;25(1):12-20.

Evidence Table
CONSENSUS SCORE
REFERENCE #

93 Thomas AN, Taylor RJ. An analysis of Nonexperimental 2238 incident reports n/a n/a Reasons for Current information about medications should be IIIB
patient safety incidents associated medication errors available to those administering the medications.
with medications reported from
critical care units in the north west of
England between 2009 and 2012.
Anaesthesia. 2014;69(7):735-745.
94 Alex S, Adenew AB, Arundel C, Maron Organizational Control 134 patients, Clinical pharmacist No clinical pharmacist Medication Assistance from a clinical pharmacist can decrease VA
DD, Kerns JC. Medication errors Experience Intervention 145 patients, assistance assistance discrepancies at medication discrepancies at discharge.
despite using electronic health admitted under the care of discharge.
records: the value of a clinical one of two medicine
pharmacist service in reducing teams.
discharge-related medication errors.
Qual Manag Health Care.
2016;25(1):32-37.
95 Abbasinazari M, Hajhossein Talasaz A, Nonexperimental 132 patients admitted to n/a n/a Medication errors Involvement of a pharmacist can decrease the number IIIA
Eshraghi A, Sahraei Z. Detection and two units in an Iranian found by pharmacist of medication errors.
management of medication errors in hospital.
internal wards of a teaching hospital
by clinical pharmacists. Acta Med
Iran. 2013;51(7):482-486.
96 Cesarz JL, Steffenhagen AL, Svenson J, Nonexperimental 674 discharge n/a n/a Pharmacist Pharmacist review of prescriptions decreased the IIIB
Hamedani AG. Emergency prescriptions interventions on suboptimal prescriptions and is valued by ED care
department discharge prescription discharge prescriptions providers
interventions by emergency medicine
pharmacists. Ann Emerg Med.
2013;61(2):209-214.
97 Ernst AA, Weiss SJ, Sullivan A4, et al. Nonexperimental 452 patients pre, 242 Presence of a pharmacist Pharmacist not present Medication errors A pharmacist in the ED may reduce medication errors. IIIB
On-site pharmacists in the ED improve patients post found by pharmacist
medical errors. Am J Emerg Med.
2012;30(5):717-725.
98 Ho L, Akada K, Messner H, Kuruvilla J, Organizational 35 patients, 100 visits to n/a n/a Number of medication Medication reconciliation performed by a pharmacist VA
Wright J, Seki JT. Pharmacist’s role in Experience clinic discrepancies. identified medication discrepancies thereby improving
improving medication safety for medication safety.
patients in an allogeneic
hematopoietic cell transplant
ambulatory clinic. Can J Hosp Pharm.
2013;66(2):110-117.

Evidence Table
CONSENSUS SCORE
REFERENCE #

99 Jiang S, Zheng X, Li X, Lu X. Nonexperimental 409 patients pre, 416 Presence of a pharmacist No pharmacist Number of medication The interventions performed by a pharmacist in the ICU IIIB
Effectiveness of pharmaceutical care patients post involvement errors and cost savings. prevented medication errors and decreased cost.
in an intensive care unit from china. A
pre- and post-intervention study.
Saudi Med J. 2012;33(7):756-762.
100 Jiang SP, Zhu ZY, Wu XL, Lu XY, Zhang Nonexperimental 103 patients pre, 106 Presence of a pharmacist No pharmacist Number of dosing The interventions performed by a pharmacist in the ICU IIIB
XG, Wu BH. Effectiveness of patients post. involvement adjustments prevented medication errors.
pharmacist dosing adjustment for
critically ill patients receiving
continuous renal replacement
therapy: a comparative study. Ther
Clin Risk Manag. 2014;10:405-412.
101 Mergenhagen KA, Blum SS, Kugler A, Quasi-experimental 102 admissions Pharmacist completed Physician completed Prescribing errors Pharmacist completed reconciliation was more IIB
et al. Pharmacist- versus physician- pharmacist, 116 medication reconciliation. medication comprehensive and had lower odds of prescribing errors
initiated admission medication admissions physician. reconciliation. than physician completed medication reconciliation.
reconciliation: impact on adverse
drug events. Am J Geriatr
Pharmacother. 2012;10(4):242-250.
102 ASHP statement on the pharmacist’s Guideline n/a n/a n/a n/a Guideline which describes the pharmacist role in IVC
role in medication reconciliation. Am J medication reconciliation.
Health Syst Pharm. 2013;70(5):453-
456.
103 Phatak A, Prusi R, Ward B, et al. RCT 141 patients in control Pharmacist involvement in No pharmacy Readmission or ED Readmission rates, ED visits, medication errors, and IB
Impact of pharmacist involvement in group, 137 patients in medication reconciliation, involvement visits, adverse drug adverse drug events decreased. HCAPHPS scores
the transitional care of high-risk study group education and post events, medication increased with pharmacist involvement.
patients through medication discharge follow-up. errors, HCAHPS scores.
reconciliation, medication education,
and postdischarge call-backs (IPITCH
Study). J Hosp Med. 2016;11(1):39-44.
104 Lenssen R, Heidenreich A, Schulz JB, Nonexperimental 306 patients admitted to n/a n/a Drug-related problems A pharmacist can identify potential drug related IIIB
et al. Analysis of drug-related three different units in a problems and may be an option to address the issue of
problems in three departments of a German hospital. medication errors.
German university hospital. Int J Clin
Pharm. 2016;38(1):119-126.

Evidence Table
CONSENSUS SCORE
REFERENCE #

105 Ibanez-Garcia S, Rodriguez-Gonzalez Nonexperimental Six pharmacists n/a n/a Number of pharmacist Pharmacy validation of medication orders decreases IIIB
CG, Martin-Barbero ML, Sanjurjo-Saez interventions and the potential medication errors and has a cost benefit.
M, Herranz-Alonso A; iPharma. estimated cost of the
Adding value through pharmacy error if no intervention
validation: a safety and cost present.
perspective. J Eval Clin Pract.
2016;22(2):253-260.
106 Fernandez-Llamazares CM, Calleja- Nonexperimental 61,458 orders on pediatric n/a n/a Interventions by Interventions by a pharmacist assisted in decreasing IIIA
Hernandez M, Manrique-Rodriguez S, patients and 119,333 pharmacy medication errors.
Perez-Sanz C, Duran-Garcia E, orders on adult patients.
Sanjurjo-Saez M. Prescribing errors
intercepted by clinical pharmacists in
paediatrics and obstetrics in a tertiary
hospital in Spain. Eur J Clin
Pharmacol. 2012;68(9):1339-1345.
107 Zaal RJ, Jansen MMPM, Duisenberg- Nonexperimental 1206 prescriptions n/a n/a Drug related problems More drug related problems were detected by a clinical IIIB
van Essenberg M, Tijssen CC, pharmacist than by the computerized prescriber order
Roukema JA, van den Bemt PMLA. entry system alerts.
Identification of drug-related
problems by a clinical pharmacist in
addition to computerized alerts. Int J
Clin Pharm. 2013;35(5):753-762.
108 Kuo GM, Touchette DR, Marinac JS. Nonexperimental 676 pharmacists n/a n/a Results of pharmacists Medication errors were caught by the pharmacist prior IIIB
Drug errors and related interventions interventions. to reaching the patient.
reported by United States clinical
pharmacists: the American College of
Clinical Pharmacy practice-based
research network medication error
detection, amelioration and
prevention study. Pharmacotherapy.
2013;33(3):253-265.

Evidence Table
CONSENSUS SCORE
REFERENCE #

109 Caroff DA, Bittermann T, Leonard CE, Quasi-experimental 981 discharges pre, 1,207 Pharmacist reconciliation Resident reconciliation Medication The identification of errors during discharge IIA
Gibson GA, Myers JS. A medical discharges post. reconciliation reconciliation improved when the reconciliation was
resident-pharmacist collaboration discrepancies. performed by a pharmacist compared to the
improves the rate of medication reconciliation being performed by the resident.
reconciliation verification at
discharge. Jt Comm J Qual Patient Saf.
2015;41(10):457-461.
110 Graabaek T, Kjeldsen LJ. Medication Systematic Review n/a n/a n/a n/a The implementation of a clinical pharmacy service assists IIIB
reviews by clinical pharmacists at with reducing medication errors.
hospitals lead to improved patient
outcomes: a systematic review. Basic
Clin Pharmacol Toxicol.
2013;112(6):359-373.
111 Han J, Ah Y, Suh SY, et al. Clinical and Nonexperimental 435 patients n/a n/a Pharmacy The involvement of a pharmacist decreased medication IIIB
economic impact of pharmacists’ interventions errors and had a positive economic impact.
intervention in a large volume
chemotherapy preparation unit. Int J
Clin Pharm. 2016;38(5):1124-1132.
112 Khalili H, Farsaei S, Rezaee H, Dashti- Nonexperimental 861 patients n/a n/a Potential medication The clinical pharmacist prevented medication errors by IIIB
Khavidaki S. Role of clinical errors detecting prescribing errors including wrong dose, wrong
pharmacists’ interventions in medication, wrong indication and potential interactions.
detection and prevention of
medication errors in a medical ward.
Int J Clin Pharm. 2011;33(2):281-284.
113 Hohmann C, Neumann-Haefelin T, Nonexperimental 155 patients diagnosed n/a n/a Drug related problems Drug related problems occur during any phase of the IIIB
Klotz JM, Freidank A, Radziwill R. Drug- with an ischemic stroke process and the clinical pharmacist can identify and
related problems in patients with and were, taking more resolve drug related problems in this population.
ischemic stroke in hospital. Int J Clin than two medications on
Pharm. 2012;34(6):828-831. admission and discharge

Evidence Table
CONSENSUS SCORE
REFERENCE #

114 Galvin M, Jago-Byrne M, Fitzsimons Nonexperimental 1556 medication orders n/a n/a Frequency of Clinical pharmacists should perform medication IIIB
M, Grimes T. Clinical pharmacist’s from 134 patients who pharmacist's activities, reconciliation on admission to the emergency
contribution to medication were at least 18 years of frequency and nature department.
reconciliation on admission to age, taking at least 3 of unresolved
hospital in Ireland. Int J Clin Pharm. medications, and were discrepancies at 48
2013;35(1):14-21. admitted to two acute hours post admission,
teaching hospitals in potential for harm
Ireland. averted by clinical
pharmacist.
115 Pal A, Babbott S, Wilkinson ST. Can Quasi-experimental 537 patients intervention Discharge review by a No pharmacist review 30-day readmission The 30-day readmission rate was decreased after the IIB
the targeted use of a discharge group, 192 control group. pharmacist rate. implementation of a pharmacy discharge reconciliation
pharmacist significantly decrease 30- program.
day readmissions? Hosp Pharm.
2013;48(5):380-388.
116 Reis WCT, Scopel CT, Correr CJ, Nonexperimental 6,438 prescriptions n/a n/a Interventions Prescribing errors were caught by the pharmacist prior IIIB
Andrzejevski VMS. Analysis of clinical performed by to the incorrect medication reaching the patient.
pharmacist interventions in a tertiary pharmacist to correct
teaching hospital in Brazil. Einstein. prescribing error.
2013;11(2):190-196.
117 Warden BA, Freels JP, Furuno JP, Quasi-experimental 35 patients intervention Pharmacy led patient No education Readmission rates Readmission rates decreased after pharmacy led IIB
Mackay J. Pharmacy-managed group, 115 control group. education medication reconciliation and discharge instructions.
program for providing education and
discharge instructions for patients
with heart failure. Am J Health Syst
Pharm. 2014;71(2):134-139.
118 Stasiak P, Afilalo M, Castelino T, et al. Nonexperimental 3,136 prescriptions n/a n/a Medication errors Pharmacists find errors and are able to intervene to IIIA
Detection and correction of found by pharmacist. correct the error.
prescription errors by an emergency
department pharmacy service. Can J
Emerg Med. 2014;16(3):193-206.
119 Balling L, Erstad BL, Weibel K. Impact Nonexperimental 1,011 patients discharged n/a n/a Readmission rates and A pharmacist should assist with educating patients on IIIC
of a transition-of-care pharmacist from an academic medical medication hospital discharge, intercepting medication errors, and
during hospital discharge. J Am Pharm center. interventions made by resolving insurance issues.
Assoc. 2015;55(4):443-448. the pharmacist at
discharge.

Evidence Table
CONSENSUS SCORE
REFERENCE #

120 Tripathi S, Crabtree HM, Fryer KR, Nonexperimental 10,963 PICU patients Pharmacist involvement in No pharmacy Number of adverse The involvement of a pharmacist decreased medication IIIB
Graner KK, Arteaga GM. Impact of care of PICU patients. involvement drug events. errors.
clinical pharmacist on the pediatric
intensive care practice: an 11-year
tertiary center experience. J Pediatr
Pharmacol Ther. 2015;20(4):290-298.
121 Sebaaly J, Parsons LB, Pilch NAW, Nonexperimental 67 medication discharge n/a n/a Cost savings, potential Pharmacist involvement resulted in cost savings, IIIB
Bullington W, Hayes GL, Easterling H. medication reviews. medication errors and reduction in medication errors and reduction in 30-day
Clinical and financial impact of 30-day readmission readmission rate.
pharmacist involvement in discharge rate.
medication reconciliation at an
academic medical center: a
prospective pilot study. Hosp Pharm.
2015;50(6):505-513.
122 Hamblin S, Rumbaugh K, Miller R. Nonexperimental 2,331 patients admitted to n/a n/a Number of pharmacy The use of a pharmacist decreased the number of IIIB
Prevention of adverse drug events trauma unit. interventions. medication errors reaching the patient and is cost
and cost savings associated with effective.
PharmD interventions in an academic
level I trauma center: an evidence-
based approach. J Trauma Acute Care
Surg. 2012;73(6):1484-1490.
123 Cochran GL, Haynatzki G. Comparison Nonexperimental 9 critical access hospitals, n/a n/a Medication errors Critical access hospitals have lower medication error IIIC
of medication safety effectiveness 350 observations. rates when a pharmacist is present at least 40 hours per
among nine critical access hospitals. week.
Am J Health Syst Pharm.
2013;70(24):2218-2224.
124 McCoy AB, Cox ZL, Neal EB, et al. Real- RCT 278 patients control group, Implementation of No pharmacy Potential errors. Pharmacy surveillance had no incremental benefit over IA
time pharmacy surveillance and 262 intervention group pharmacy surveillance surveillance the existing clinical decision support system.
clinical decision support to reduce
adverse drug events in acute kidney
injury: a randomized, controlled trial.
Appl Clin Inform. 2012;3(2):221-238.

Evidence Table
CONSENSUS SCORE
REFERENCE #

125 van den Bemt PMLA, van der Schrieck- Quasi-experimental 1543 ED hospital Use of a pharmacist to Pharmacist or Number of medication A pharmacist lead medication history contains fewer IIA
de Loos EM, van der Linden C, admissions obtain medication history. physician obtained discrepancies. errors than a history obtained by a mixed model
Theeuwes AMLJ, Pol AG; Dutch CBO medication history. (physician or a pharmacist).
WHO High 5s Study Group. Effect of
medication reconciliation on
unintentional medication
discrepancies in acute hospital
admissions of elderly adults: a
multicenter study. J Am Geriatr Soc.
2013;61(8):1262-1268.
126 Bishop MA, Cohen BA, Billings LK, Nonexperimental 104 patients n/a n/a Medication A pharmacist should be included in the medication IIIB
Thomas EV. Reducing errors through discrepancies reconciliation process.
discharge medication reconciliation
by pharmacy services. Am J Health
Syst Pharm. 2015;72(17 Suppl 2):S120-
S126.
127 Gardella JE, Cardwell TB, Nnadi M. Organizational 1,251 patients n/a n/a Medication There were a lower number of discrepancies on a VA
Improving medication safety with Experience discrepancies and rate admission medication completed by a pharmacist than
accurate preadmission medication of readmissions. those completed by an RN. The patients having a post
lists and postdischarge education. Jt discharge phone call from a pharmacist had lower rate of
Comm J Qual Patient Saf. readmissions.
2012;38(10):452-458.
128 Kramer JS, Stewart MR, Fogg SM, et Nonexperimental 153 ED patients n/a n/a Number of Pharmacists found the highest number of discrepancies IIIB
al. A quantitative evaluation of discrepancies compared to nurses and pharmacy technicians.
medication histories and
reconciliation by discipline. Hosp
Pharm. 2014;49(9):826-838.
129 Beckett RD, Crank CW, Wehmeyer A. RCT 41 pharmacy group, 40 Pharmacy performed Resident or intern Medication During medication reconciliation pharmacists found IB
Effectiveness and feasibility of resident /intern group medication reconciliation performed discrepancies. more discrepancies compared to the discrepancies
pharmacist-led admission medication reconciliation found by the medical resident or the intern.
reconciliation for geriatric patients. J
Pharm Pract. 2012;25(2):136-141.

Evidence Table
CONSENSUS SCORE
REFERENCE #

130 Aag T, Garcia BH, Viktil KK. Should RCT 201 patients Pharmacist group Nurse group Time taken for The pharmacist required less time to complete the IA
nurses or clinical pharmacists perform reconciliation and reconciliation process than the nurses, but there was not
medication reconciliation? A number of a statistical difference in the number of errors found.
randomized controlled trial. Eur J Clin discrepancies.
Pharmacol. 2014;70(11):1325-1332.
131 Zemaitis CT, Morris G, Cabie M, Nonexperimental 465 patients in Medication reconciliation No reconciliation or 30-day readmission Medication reconciliation and patient education by a IIIB
Abdelghany O, Lee L. Reducing intervention group/ and patient education at discharge education. rates. pharmacist decreased 30-day readmission rates.
readmission at an academic medical patients admitted one year discharge.
center: results of a pharmacy- earlier during same time
facilitated discharge counseling and frame.
medication reconciliation program.
Hosp Pharm. 2016;51(6):468-473.
132 Centers for Medicare & Medicaid Regulatory n/a n/a n/a n/a CMS regulations for the ambulatory surgery center. n/a
Services. State Operations Manual
Appendix L—Guidance for Surveyors:
Ambulatory Surgical Centers. Rev.
137; 2015.
https://www.cms.gov/Regulations-
and-
Guidance/Guidance/Manuals/downlo
ads/som107ap_l_ambulatory.pdf.
Accessed July 12, 2017.
133 Cole SL, Grubbs JH, Din C, Nesbitt TS. Quasi-experimental 500 prescriptions pre; 504 Use of telepharmacy Non-tele pharmacist Medication errors Adverse patient outcomes can be prevented by use of IIB
Rural inpatient telepharmacy prescriptions post. found by pharmacist. telepharmacy.
consultation demonstration for after-
hours medication review. Telemed J E
Health. 2012;18(7):530-537.
134 The Joint Commission. Preventing Expert Opinion n/a n/a n/a n/a Provides recommendations for use of single use vials. VB
infection from the misuse of vials.
Sentinel Event Alert. June 16,
2014;52.
https://www.jointcommission.org/se
a_issue_52/. Accessed July 12, 2017.
135 Horvath G, MacGregor RL. Is your Expert Opinion n/a n/a n/a n/a Educate personnel on proper medication disposal, do VB
facility properly managing not use single dose vials, conduct audits to verify
pharmaceutical waste? OR Nurse. disposal techniques are being adhered to.
2013;7(5):8-12.

Evidence Table
CONSENSUS SCORE
REFERENCE #

136 Buck D, Subramanyam R, Varughese Organizational All patients admitted to n/a n/a Number of patients Wasting of Fentanyl and the number of patients who VA
A. A quality improvement project to Experience one busy OR. who received Fentanyl received Fentanyl from single dose vials used on more
reduce the intraoperative use of from single dose vials than one patient decreased after purchasing smaller
single-dose fentanyl vials across used on more than one volume vials.
multiple patients in a pediatric patient.
institution. Paediatr Anaesth.
2016;26(1):92-101.
137 Yadav G, Gupta SK, Bharti AK, Khuba Case Report n/a n/a n/a n/a Look-alike medications should be stored in separate VC
S, Jain G, Singh DK. Case report: locations, double check medications before
syringe swap and similar looking drug administration, medications syringes should be labeled
containers: a matter of serious and label should be read carefully.
concern. Anaesth Pain Intensive Care.
2013;17(2):205-207.
138 Fry RA, Wilton N, Boyes G. Unusual Case Report n/a n/a n/a n/a An isoflurane bottle was emptied and the solution VC
volatile agent switch: implications for replaced with cleaning solution therefore these bottles
checking unsealed volatile agent should be stored in a locked compartment.
containers. Anaesth Intensive Care.
2015;43(3):419-420.
139 De Winter S, Vanbrabant P, Vi NTT, et Nonexperimental Laboratory study, 4 n/a n/a Medication Temperature sensitive medications deteriorate when IIIB
al. Impact of temperature exposure medications deterioration stored at temperatures beyond recommended ranges.
on stability of drugs in a real-world
out-of-hospital setting. Ann Emerg
Med. 2013;62(4):380-387.
140 Grissinger M. Ambulatory surgery Nonexperimental 502 medication error n/a n/a Types of medication Report for the state of Pennsylvania containing IIIB
facilities: a comprehensive review of reports errors. medication error statistics from ambulatory surgery
medication error reports in centers and recommendations for interventions to take
Pennsylvania. Penn Patient Saf Advis. to reduce the number of errors.
2011;8(3):85-93.
141 Tobias JD, Yadav G, Gupta SK, Jain G. Expert Opinion n/a n/a n/a n/a Provides recommendations for preventing medication VB
Medication errors: a matter of serious errors.
concern. Anaesth Pain Intensive Care.
2013;17(2):111-114.
142 Anto B, Barlow D, Oborne CA, Nonexperimental 911 dispensing errors n/a n/a Predisposing factors to Medication selection errors are related to confusion IIIB
Whittlesea C. Incorrect drug selection medication errors. caused by look-alike/sound-alike medications.
at the point of dispensing: a study of
potential predisposing factors. Int J
Pharm Pract. 2011;19(1):51-60.
143 Medication safety. J Pharm Pract Res. Case Report n/a n/a n/a n/a Case report of medication error related to confusion VC
2011;41(2):139-143. caused by look-alike names.

Evidence Table
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REFERENCE #

144 Medication safety. J Pharm Pract Res. Case Report n/a n/a n/a n/a Case report of medication error related to confusion VC
2011;41(1):52-56. caused by look-alike labels.
145 Cote V, Prager JD. Iatrogenic phenol Case Report n/a n/a n/a n/a The wrong medication was selected from the cabinet VC
injury: a case report and review of when the medications were in look-alike containers and
medication safety and labeling had look-alike labels.
practices with flexible laryngoscopy.
Int J Pediatr Otorhinolaryngol.
2014;78(10):1769-1773.
146 Cohen MR, Smetzer JL. ISMP Case Report n/a n/a n/a n/a A patient received the wrong medication because of a VC
medication error report look-alike situation. A patient received the wrong IV
analysis—FDA advise-ERR: FDA solution after being connected to the roommates
approves hydromorphone labeling solution.
revisions to reduce medication errors;
differentiating penicillin from
penicillamine; infusion reconnected
to the wrong patient; spell out
acetaminophen on. Hosp Pharm.
2012;47(1):10-13.
147 Cohen MR, Smetzer JL. ISMP Case Report n/a n/a n/a n/a Medication mix-up occurred because of look-alike VC
medication error report names.
analysis—drug stability and
compatibility; proper use of single-
dose vials; what drugs are present on
nursing units?; Arixtra—not a
hemostat; Pradaxa-Plavix mix-up.
Hosp Pharm. 2012;47(8):578-582.
148 Butala BP, Shah VR, Bhosale GP, Shah Case Report n/a n/a n/a n/a Case report of medication error related to the use of the VC
RB. Medication error: subarachnoid wrong medication when two medications labels were
injection of tranexamic acid. Indian J similar.
Anaesth. 2012;56(2):168-170.
149 Koczmara C, Hyland S. Drug name Case Report n/a n/a n/a n/a Case report describing a case where Pardax was given VB
alert: potential for confusion between instead of Plavix therefore separate storage areas are
Pradaxa and Plavix. Dynamics. advised.
2011;22(3):25-26.
150 Vazin A, Zamani Z, Hatam N. Nonexperimental 202 patients admitted to a n/a n/a Medication errors Medication errors occurred during the administration, IIIB
Frequency of medication errors in an Canadian emergency prescription, and transcription, phases.
emergency department of a large department.
teaching hospital in southern Iran.
Drug Healthc Patient Saf. 2014;6:179-
184.

Evidence Table
CONSENSUS SCORE
REFERENCE #

151 Zeraatchi A, Talebian M, Nejati A, Nonexperimental 500 Iranian ED patients. n/a n/a Frequency of Medication error occurred during the prescription, IIIB
Dashti-Khavidaki S. Frequency and 1291 medications medication errors transcription, and administration phases.
types of the medication errors in an administered.
academic emergency department in
Iran: the emergent need for clinical
pharmacy services in emergency
departments. J Res Pharm Pract.
2013;2(3):118-122.
152 Manias E, Kinney S, Cranswick N, Nonexperimental 274 discharge n/a n/a Prescribing and Medication errors occur during the prescribing and IIIB
Williams A. Medication errors in prescriptions transcribing errors. transcribing phases of the medication use process.
hospitalised children. J Paediatr Child
Health. 2014;50(1):71-77.
153 21 USC 13: Drug Abuse Prevention Regulatory n/a n/a n/a n/a All medications must be prescribed by a licensed n/a
and Control. Subchapter I: Control practitioner.
and enforcement (sections 801-904).
US Government Publishing Office.
https://www.gpo.gov/fdsys/granule/
USCODE-2011-title21/USCODE-2011-
title21-chap13/content-detail.html.
154 Guideline for patient information Guideline n/a n/a n/a n/a Recommendations address requirements for IVA
management. In: Guidelines for perioperative nursing documentation.
Perioperative Practice. Denver, CO:
AORN, Inc; 2017:591-616.
155 Neuss MN, Polovich M, McNiff K, et Guideline n/a n/a n/a n/a Guidelines for administration of chemotherapeutic IVB
al. 2013 updated American society of medications.
clinical oncology/oncology nursing
society chemotherapy administration
safety standards including standards
for the safe administration and
management of oral chemotherapy. J
Oncol Pract. 2013;9(2 Suppl):5s-13s.

Evidence Table
CONSENSUS SCORE
REFERENCE #

156 Shawahna R, Rahman N, Ahmad M, Nonexperimental 6,583 inpatient n/a n/a Medication errors The use of tall man lettering, covered decimal points and IIIB
Debray M, Yliperttula M, Decleves X. prescriptions, 5,329 not using trailing zeros with decimal units reduced
Impact of prescriber’s handwriting outpatient prescriptions. medication errors.
style and nurse’s duty duration on the
prevalence of transcription errors in
public hospitals. J Clin Nurs. 2013;22(3-
4):550-558.
157 Cohen MR, Smetzer JL. Dangerous Case Report n/a n/a n/a n/a Case report of a non-approved abbreviation being used VC
close call with wintergreen oil; are 10 and leading to a medication error.
mL syringes needed when giving drugs
via venous access devices?; use of
“NoAC” abbreviation; unsafe
frequency notation; 2014-15 targeted
medication safety best practices for
hospitals. Hosp Pharm.
2014;49(4):325-328.
158 Paul IM, Neville K, Galinkin JL, et al. Guideline n/a n/a n/a n/a Recommendations address the use of metric IVC
Metric units and the preferred dosing abbreviations
of orally administered liquid
medications. Pediatrics.
2015;135(4):784-787.
159 ISMP guidelines for standard order Guideline n/a n/a n/a n/a Guideline covering standard order sets. IVC
sets. Institute for Safe Medication
Practices.
http://www.ismp.org/Tools/guideline
s/StandardOrderSets.asp. Accessed
July 12, 2017.
160 Sakushima K, Umeki R, Endoh A, Ito Nonexperimental 2867 medication error n/a n/a Number of medication A bar-code medication administration system is an IIIB
YM, Nasuhara Y. Time trend of reports errors before and after effective method to prevent wrong patient medication
injection drug errors before and after instituting a bar-code errors.
implementation of bar-code medication
verification system. Technol Health administrations
Care. 2015;23(3):267-274. system.
161 Al-Shaiji TF. Achieving detumescence Case Report n/a n/a n/a n/a Case report of a medication error resulting from a VC
of ischemic priapism with intra- misunderstood verbal order.
cavernosal injection of fentanyl: an
unexpected outcome of
miscommunication error. Curr Drug
Saf. 2011;6(3):194-196.

Evidence Table
CONSENSUS SCORE
REFERENCE #

162 Recommendations to reduce Guideline n/a n/a n/a n/a Guideline covering standard order sets. IVC
medication errors associated with
verbal medication orders and
prescriptions. National Coordinating
Council for Medication Error
Reporting and Prevention.
http://www.nccmerp.org/recommen
dations-reduce-medication-errors-
associated-verbal-medication-orders-
and-prescriptions. Adopted February
20, 2001. Revised May 1, 2015.
163 Hicks RW, Becker SC, Windle PE, Nonexperimental 3,023 medication error n/a n/a Frequency of types of Report describing the frequency of various types of IIIC
Krenzischek DA. Medication errors in reports medication errors. medication errors.
the PACU. J Perianesth Nurs.
2007;22(6):413-419.
164 Hicks RW, Becker SC, and Cousins DD. Nonexperimental 11,239 medication errors n/a n/a Frequency of types of Report describing the frequency of various types of IIIC
MEDMARX Data Report: A Chartbook medication errors. medication errors.
of Medication Error Findings from the
Perioperative Settings from 1998-
2005. Rockville, MD: US
Pharmacopeia; 2007.
165 Pharmaceutical compounding—sterile Guideline n/a n/a n/a Clinical practice The recommendations address the precautions to be IVB
preparations (797). In: USP guidelines for taken when compounding medications
Compounding Compendium. compounding
Rockville, MD: US Pharmacopeial medications including
Convention; 2016:40-85. time for disposal
166 Matousek P, Kominek P, Garcic A. Case Report n/a n/a n/a n/a Medication dilutions should be prepared outside the OR. VC
Errors associated with the Dilutions of the same medications prepared in the facility
concentration of epinephrine in should have different colored labels.
endonasal surgery. Eur Arch
Otorhinolaryngol. 2011;268(7):1009-
1011.

Evidence Table
CONSENSUS SCORE
REFERENCE #

167 Dehmel C, Braune SA, Kreymann G, et Nonexperimental 100 admixtures made in n/a n/a Medication Medication admixtures should be prepared in the IIIB
al. Do centrally pre-prepared pharmacy and 100 concentration pharmacy using mechanical assistance.
solutions achieve more reliable drug admixtures made in
concentrations than solutions nursing unit.
prepared on the ward? Intensive Care
Med. 2011;37(8):1311-1316.
168 Patel S, Loveridge R. Obstetric Systematic Review n/a n/a n/a Reports of medication Labels must be carefully read, all syringes must be IIIB
neuraxial drug administration errors: errors. labeled, labels should be double checked with another
a quantitative and qualitative individual or a machine and only non-Leur lock
analytical review. Anesth Analg. connections should be used on spinal-epidural devices.
2015;121(6):1570-1577.
169 Cohen MR, Smetzer JL. ISMP Case Report n/a n/a n/a n/a Medication names should not be abbreviated, truncated, VC
medication error report stemmed or shortened on medication labels.
analysis—important change with
heparin labels; Benadryl dispensed
instead of vitamins for home
parenteral nutrition; potassium and
sodium acetate injection mix-ups;
don’t truncate, stem, or shorten drug
names. Hosp Pharm. 2013;48(4):267-
269.
170 Cohen M, Smetzer J. ISMP medication Expert Opinion n/a n/a n/a n/a Tallman lettering should be used. VC
error report analysis—preventing mix-
ups between various formulations of
amphotericin B; Arixtra is not a
hemostat; measurement mix-up; drug
names too close for comfort; new
vaccine errors reporting program.
Hosp Pharm. 2013;48(2):95-98.
171 Emmerton L, Rizk MFS, Bedford G, 250 pairs of confusable Application of Tall Man No Tall Man Confusable drug names Tall Man lettering should be used on labels to identify IIIB
Lalor D. Systematic derivation of an drug names lettering confusable medications.
Australian standard for tall man
lettering to distinguish similar drug
names. J Eval Clin Pract.
2015;21(1):85-90.

Evidence Table
CONSENSUS SCORE
REFERENCE #

172 Darker IT, Gerret D, Filik R, Purdy KJ, Nonexperimental 52 medics, 36 pharmacists, Tallman lettering Lower case lettering Accuracy of reading Use of tall man lettering on medication labels increased IIIB
Gale AG. The influence of “tall man” 45 pharmacy technicians names of look-alike accuracy in drug name perception.
lettering on errors of visual from United Kingdom. medications.
perception in the recognition of
written drug names. Ergonomics.
2011;54(1):21-33.
173 DeHenau C, Becker MW, Bello NM, Nonexperimental 16 nurses, 24 other health Tallman lettering Lower case lettering Accuracy of reading Tallman lettering on medication labels should be used IIIB
Liu S, Bix L. Tallman lettering as a care providers, 40 lay names of look-alike help to reduce medication errors.
strategy for differentiation in look- people. medications.
alike, sound-alike drug names: the
role of familiarity in differentiating
drug doppelgangers. Appl Ergon.
2016;52:77-84.
174 Or CKL, Chan AHS. Effects of text Nonexperimental 60 individuals reviewed Label text enhancements All labels contain lower Drug name Text enhancement (eg, tall man lettering increases name IIIB
enhancements on the differentiation 120 pairs of drug names. (eg, Tall man lettering). case lettering. differentiation differentiation of look-alike drugs.
performance of orthographically
similar drug names. Work.
2014;48(4):521-528.
175 Trudeau M, Green E, Cosby R, et al. Guideline n/a n/a n/a n/a Evidence based guideline for contents of medication IVB
Key components of intravenous labels.
chemotherapy labeling: a systematic
review and practice guideline. J Oncol
Pharm Pract. 2011;17(4):409-424.
176 Harkanen M, Turunen H, Saano S, Nonexperimental 671 medication error n/a n/a Medication errors Medication errors were detected from medication error IIIB
Vehvilainen-Julkunen K. Detecting reports reports to occur in all phases of the medication process.
medication errors: analysis based on The researchers recommend that interruptions are
a hospital’s incident reports. Int J Nurs decreased during the administration of medications.
Pract. 2015;21(2):141-146.
177 Barak M, Greenberg Z, Danino J. Case Report n/a n/a n/a n/a Report of a case where a 13 year old received a dose of VC
Delayed awakening following remifentanil 10 times greater then recommended. Error
inadvertent high-dose remifentanil was the result of an dosage miscalculation.
infusion in a 13 year old patient. J Clin
Anesth. 2011;23(4):322-324.

Evidence Table
CONSENSUS SCORE
REFERENCE #

178 Cohen MR, Smetzer JL. ISMP Case Report n/a n/a n/a n/a Case report describing a mix-up in names and a case of VC
medication error report inadequate monitoring.
analysis—tragedy in the
postanesthesia care unit; mix-ups
between risperidone and ropinirole.
Hosp Pharm. 2013;48(7):538-541.
179 Medication safety. J Pharm Pract Res. Case Report n/a n/a n/a n/a Case report of medication name mix-ups. VC
2014;44(1):38-43.
180 Cohen MR, Smetzer JL. ISMP Case Report n/a n/a n/a n/a Case report of a medication error resulting from look- VC
medication error report alike medication labels.
analysis—leucovorin-levoleucovorin
mix-up; two error-reduction
principles, one change; syringe pull-
back method of verifying IV
admixtures is unreliable; fleet enema
saline is not just saline; ISMP
processes health IT. Hosp Pharm.
2013;48(10):803-806.
181 Cohen MR, Smetzer JL. U-500 insulin Case Report n/a n/a n/a n/a Medication error was related to name mix-ups. VC
safety concerns mount; improved
labeling needed for camphor product;
cardizem-cardene mix-up; initiative to
eliminate tubing misconnections.
Hosp Pharm. 2014;49(2):117-120.
182 Cohen MR, Smetzer JL. ISMP Case Report n/a n/a n/a n/a Patients should receive education regarding proper VC
medication error report analysis. medication administration.
Hosp Pharm. 2015;50(5):347-350.
183 Shridhar Iyer U, Fah KK, Chong CK, Qualitative 176 anesthesiologists n/a n/a Medication errors. Medication errors occur in the including swapping of IIIC
Macachor J, Chia N. Survey of syringes, and accidental injection of an incorrect
medication errors among medication.
anaesthetists in Singapore. Anaesth
Intensive Care. 2011;39(6):1151-1152.
184 Kanji S, Lam J, Goddard RD, et al. Nonexperimental 434 ICU patients n/a n/a Simultaneous Two incompatible medications were observed to be IIIA
Inappropriate medication administration of two given via the same IV line.
administration practices in Canadian incompatible
adult ICUs: a multicenter, cross- medications.
sectional observational study. Ann
Pharmacother. 2013;47(5):637-643.

Evidence Table
CONSENSUS SCORE
REFERENCE #

185 Zhou L, Dhopeshwarkar N, Nonexperimental 1,766,328 patients n/a n/a Presence of Allergies are present in many patients and there is an IIIB
Blumenthal KG, et al. Drug allergies medication allergies increase in allergies to ACE inhibitors.
documented in electronic health
records of a large healthcare system.
Allergy. 2016;71(9):1305-1313.
186 Echeta G, Moffett BS, Checchia P, et Nonexperimental 85 adults, 33 pediatric n/a n/a Medication errors Medication dosage should be calculated based on the IIIB
al. Prescribing errors in adult patients weight and not the age of the patient because some
congenital heart disease patients people are large pediatric patients or small adult
admitted to a pediatric cardiovascular patients.
intensive care unit. Congenit Heart
Dis. 2014;9(2):126-130.
187 Modic MB, Albert NM, Sun Z, et al. RCT 266 patients Double checking of the No double checking of Medication errors Double checking of insulin reduced administration IB
Does an insulin double-checking insulin the insulin errors.
procedure improve patient safety? J
Nurs Adm. 2016;46(3):154-160.
188 Girard NJ. Vial mistakes involving Case Report n/a n/a n/a n/a Case report describing the results of an incorrect dose of VB
heparin. AORN J. 2011;94(6):644, 554. heparin with recommendations to correct situation.
189 Gilbar PJ, Seger AC. Fatalities resulting Case Report n/a n/a n/a n/a Case report describing three situations in which VC
from accidental intrathecal medications were given by the intrathecal route instead
administration of bortezomib: of intravenously as intended.
strategies for prevention. J Clin Oncol.
2012;30(27):3427-3428.
190 Kellett P, Gottwald M. Double- Literature Review n/a n/a n/a n/a High risk medications should be double checked prior to VC
checking high-risk medications in administration.
acute settings: a safer process. Nurs
Manag (Harrow). 2015;21(9):16-22.
191 Alsulami Z, Conroy S, Choonara I. Systematic Review 16 articles n/a n/a Efficacy of double The current evidence is insufficient to support or refute IIIB
Double checking the administration of checking medications. the practice of double checking medications. The
medicines: what is the evidence? A researchers recommend clinical trials be performed.
systematic review. Arch Dis Child.
2012;97(9):833-837.
192 Ofosu R, Jarrett P. Reducing nurse Expert Opinion n/a n/a n/a n/a Medication errors occur at many phases during the VB
medicine administration errors. Nurs medication administration process and interruptions
Times. 2015;111(20):12-14. should be reduced, nurses should be educated on
calculations.

Evidence Table
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REFERENCE #

193 Murphy M, While A. Medication Nonexperimental 59 nurses n/a n/a Medication errors Results of quality programs should be shared with all IIIB
administration practices among people involved. Interruptions should be decreased to
children’s nurses: a survey. Br J Nurs. decrease medication errors.
2012;21(15):928-933.
194 McLeod M, Barber N, Franklin BD. Nonexperimental 56 drug rounds n/a n/a Interruptions Interruptions during medication administration should IIIB
Facilitators and barriers to safe be limited.
medication administration to hospital
inpatients: a mixed methods study of
nurses’ medication administration
processes and systems (the MAPS
study). PLoS One.
2015;10(6):e0128958.
195 Raban MZ, Westbrook JI. Are Systematic Review n/a n/a n/a n/a The evidence supporting medication errors being IIA
interventions to reduce interruptions decreased by decreasing interruptions is weak but it is
and errors during medication present and processes to reduce the number of
administration effective?: a interruptions should be instituted in addition to more
systematic review. BMJ Qual Saf. research being completed.
2014;23(5):414-421.
196 Williams T, King MW, Thompson JA, Organizational 52 RNs before Implementation of a No interventions Adverse drug events Decreasing the number of interventions decreases the VB
Champagne MT. Implementing Experience implementation and 48 package of interventions. and number of number of medication errors.
evidence-based medication safety RNs after. interruptions.
interventions on a progressive care
unit. Am J Nurs. 2014;114(11):53-62.
197 Choo J, Johnston L, Manias E. Nurses’ Nonexperimental 170 nurses n/a n/a Medication Distractions and environmental factors can effect safe IIIB
medication administration practices administration errors. medication administration.
at two Singaporean acute care
hospitals. Nurs Health Sci.
2013;15(1):101-108.
198 Bower R, Jackson C, Manning JC. Systematic Review n/a n/a n/a n/a Interruptions during administration may lead to IIIB
Interruptions and medication medication errors, but there is a lack of empirical studies
administration in critical care. Nurs that demonstrate a connection between minimizing
Crit Care. 2015;20(4):183-195. interruptions and a reduction in
medication errors.

Evidence Table
CONSENSUS SCORE
REFERENCE #

199 Verweij L, Smeulers M, Maaskant JM, Nonexperimental 105 medication Wearing tabards No tabards Interruptions and The use of drug round tabards decreased the number of IIIB
Vermeulen H. Quiet please! Drug administrations pre medication errors. interruptions and simultaneously the number of
round tabards: are they effective and intervention, 104 post medication errors.
accepted? A mixed method study. J intervention period 1, 104
Nurs Scholarsh. 2014;46(5):340-348. post intervention period 2.
200 Fore AM, Sculli GL, Albee D, Neily J. Organizational n/a The sterile cockpit Survey before and Interruptions and The use of a sterile cockpit principle (ie, no-interruption VB
Improving patient safety using the Experience principle after implementation medication errors. zone, indicator or area for medication administration)
sterile cockpit principle during has a positive impact on patient safety. The researchers
medication administration: a provided examples of how to implement the sterile
collaborative, unit-based project. J cockpit principle such as use of vests or "Do Not Disturb"
Nurs Manag. 2013;21(1):106-111. signs.
201 Bravo K, Cochran G, Barrett R. Nursing Nonexperimental 1374 patients n/a n/a Interruptions during Interruptions occur frequently during the process of IIIB
strategies to increase medication medication medication administration.
safety in inpatient settings. J Nurs administration.
Care Qual. 2016;31(4):335-341.
202 Pape TM. The effect of a five-part Organizational LPNs and RNs on a single Implementation of Med No protocol Distractions and A medication safety zone should be established. Nurses VB
intervention to decrease omitted Experience medical-surgical unit. 63 Safe Protocol interruptions. in zone should not be interrupted. Nurses should wear
medications. Nurs Forum. control/57 intervention visible attire during medication administration. A
2013;48(3):211-222. group. medication safety checklist should be used. A coined
reply for should be created for nurses to use when
interrupted. Personnel should be educated regarding
actions to take to decrease interruptions.
203 Capasso V, Johnson M. Improving the Organizational n/a n/a n/a n/a Interruption during passing medications decreased with VC
medicine administration process by Experience the use of signage indicating medication administration
reducing interruptions. J Healthc in process.
Manag. 2012;57(6):384-390.
204 Craig J, Clanton F, Demeter M. Quasi-experimental 42 nurses from a variety of Wearing a white vest No vest Interruptions The use of a method to indicate "Do not interrupt: IIB
Reducing interruptions during nursing units. during medication decreases interruptions during medication
medication administration: the white administration. administration and possibly reduce medication errors.
vest study. J Res Nurs. 2014;19(3):248-
261.

Evidence Table
CONSENSUS SCORE
REFERENCE #

205 Fabbri G, Panico M, Dallolio L, et al. Case Report n/a n/a n/a n/a Failure to follow various infection control practices VC
Outbreak of ampicillin/piperacillin- resulted in infections in multiple patients. Practices not
resistant Klebsiella pneumoniae in a followed include single dose medication administered to
neonatal intensive care unit (NICU): multiple patients.
investigation and control measures.
Int J Environ Res Public Health.
2013;10(3):808-815.
206 Branch-Elliman W, Weiss D, Balter S, Case Report n/a n/a n/a n/a HCV was spread through re-use of needles and use of a VC
Bornschlegel K, Phillips M. Hepatitis C single-patient use vial on multiple patients.
transmission due to contamination of
multidose medication vials: summary
of an outbreak and a call to action.
Am J Infect Control. 2013;41(1):92-94.
207 De Smet B, Veng C, Kruy L, et al. Case Report n/a n/a n/a n/a The use of multiple dose vials should be avoided. VC
Outbreak of Burkholderia cepacia
bloodstream infections traced to the
use of Ringer lactate solution as
multiple-dose vial for catheter
flushing, Phnom Penh, Cambodia. Clin
Microbiol Infect. 2013;19(9):832-837.
208 Cohen M, Smetzer J. ISMP medication Expert Opinion n/a n/a n/a n/a Single use insulin syringes should not be used on more VC
error report analysis—error than one patient.
prevention strategies for strong
iodine solution; do not use an insulin
pen for multiple patients. Hosp
Pharm. 2012;47(4):260-263.
209 Jog M, Sachidananda R, Saeed K. Risk Nonexperimental Laboratory study n/a n/a Presence of Single use vials of lidocaine become contaminated after IIIB
of contamination of lidocaine contaminates in the first use even with the application of a new
hydrochloride and phenylephrine medication applicator and should not be used on multiple patients.
hydrochloride topical solution: in vivo The contamination occurs because of suck back.
and in vitro analyses. J Laryngol Otol.
2013;127(8):799-801.

Evidence Table
CONSENSUS SCORE
REFERENCE #

210 Baniasadi S, Dorudinia A, Mobarhan Nonexperimental 205 vials n/a n/a Medication Single and multidose vials that were opened, partially IIIB
M, Karimi Gamishan M, Fahimi F. contamination used, and were within the use date were contaminated.
Microbial contamination of single-
and multiple-dose vials after opening
in a pulmonary teaching hospital. Braz
J Infect Dis. 2013;17(1):69-73.
211 Moore ZS, Schaefer MK, Hoffmann Case Report n/a n/a n/a n/a HCV was transmitted between patients by the use of VA
KK, et al. Transmission of hepatitis C multidose vials and the use of shared needles between
virus during myocardial perfusion multiple patients.
imaging in an outpatient clinic. Am J
Cardiol. 2011;108(1):126-132.
212 Drezner K, Antwi M, Del Rosso P, Case Report n/a n/a n/a n/a A series of infections were related to the contamination VC
Dorsinville M, Kellner P, Ackelsberg J. of a multidose vial.
A cluster of methicillin-susceptible
Staphylococcus aureus infections at a
rheumatology practice, New York City,
2011. Infect Control Hosp Epidemiol.
2014;35(2):187-189.
213 King CA, Ogg M. Safe injection Expert Opinion n/a n/a n/a n/a Use a clean syringe and needle for every patient. VB
practices for administration of
propofol. AORN J. 2012;95(3):365-
372.
214 Kundra S, Singh RM, Grewal A, Gupta Case Report n/a n/a n/a n/a Report of a case of streptococcal necrotizing fasciitis VB
V, Chaudhary AK. Necrotizing fasciitis resulting from a contaminated multidose vial.
after spinal anesthesia. Acta
Anaesthesiol Scand. 2013;57(2):257-
261.
215 Ersoz G, Uguz M, Aslan G, Horasan ES, Case Report n/a n/a n/a n/a Reuse of syringes and needles when withdrawing VC
Kaya A. Outbreak of meningitis due to medications from a multiple-dose vial caused an
Serratia marcescens after spinal outbreak of meningitis.
anaesthesia. J Hosp Infect.
2014;87(2):122-125.

Evidence Table
CONSENSUS SCORE
REFERENCE #

216 Coyle JR, Goerge E, Kacynski K, et al. Case Report n/a n/a n/a n/a Medication vials should be entered with a new needle VC
Hepatitis C virus infections associated attached to a new syringe each time entered.
with unsafe injection practices at a
pain management clinic, Michigan,
2014-2015. Pain Med. 2017;18(2):322-
329.
217 Rashid M, Karagama YG. Study of Nonexperimental Laboratory study n/a n/a Contamination of There is no contamination of the nasal spray solution IIIB
microbial spread when using multiple- medication between simulated patients when the tip was changed.
use nasal anaesthetic spray.
Rhinology. 2011;49(3):281-285.
218 Hilliard JG, Cambronne ED, Kirsch JR, Nonexperimental 15 vials n/a n/a Vial rubber septum The rubber septum requires decontamination prior to IIIB
Aziz MF. Barrier protection capacity contamination insertion of needle.
of flip-top pharmaceutical vials. J Clin
Anesth. 2013;25(3):177-180.
219 Laha B, Hazra A. Medication error Case Report n/a n/a n/a n/a Case report of a label not being read closely, keeping VC
report: intrathecal administration of multiple injections together.
labetalol during obstetric anesthesia.
Indian J Pharmacol. 2015;47(4):456-
458.
220 Park JC, Herbert EN. Laser goggles Expert Opinion n/a n/a n/a n/a Laser goggles will distort the color of the labels. VC
alter the perceived colour of drug
labels, increasing the risk for drug
errors. Can J Ophthalmol.
2013;48(2):e27-e28.
221 Dolan SA, Arias KM, Felizardo G, et al. Guideline n/a n/a n/a n/a Guidelines for safe Injection ,infusion, and medication IVB
APIC position paper: safe injection, vial practices in health care.
infusion, and medication vial practices
in health care. Am J Infect Control.
2016;44(7):750-757.
222 Haas RE, Beitz E, Reed A, et al. No Nonexperimental 80 IV bags of LR n/a n/a Presence of bacteria No bacterial growth was found in the solution 8 hours IIIB
bacterial growth found in spiked after spiking.
intravenous fluids over an 8-hour
period. Am J Infect Control.
2017;45(4):448-450.
223 Preventing catheter/tubing Case Report n/a n/a n/a n/a Report of various types of tubing misconnections. VC
misconnections: much needed help is
on the way! Alta RN. 2011;67(2):24-
25.
224 Paparella SF, Wollitz A. Mix-ups and Expert Opinion n/a n/a n/a n/a Medication administration tubing should be managed VC
misconnections: avoiding intravenous only by qualified individuals.
line errors. J Emerg Nurs.
2014;40(4):382-384.

Evidence Table
CONSENSUS SCORE
REFERENCE #

225 Simmons D, Phillips MS, Grissinger M, Expert Opinion n/a n/a n/a n/a Personnel should be educated about types of tubing, VB
Becker SC; USP Safe Medication Use making correct connections. Only syringes intended for
Expert Committee. Error-avoidance IV use should be used for IV injections. Policy and
recommendations for tubing procedures should include the need to trace lines.
misconnections when using Luer-tip
connectors: a statement by the USP
safe medication use expert
committee. Jt Comm J Qual Patient
Saf. 2008;34(5):293-296, 245.
226 Döring M, Brenner B, Handgretinger Case Report n/a n/a n/a n/a Breast milk was given intravenously which could have VC
R, Hofbeck M, Kerst G. Inadvertent been prevented if the tubing connections were
intravenous administration of incompatible.
maternal breast milk in a six-week-old
infant: a case report and review of the
literature. BMC Res Notes. 2014;7:17.
227 Cohen MR, Smetzer JL. ISMP Case Report n/a n/a n/a n/a A case report of a patient receiving a medication IV that VC
medication error report analysis. was intended to be given as a wound irrigant.
Hosp Pharm. 2011;46(2):82-86.
228 Cohen MR, Smetzer JL. ISMP Case Report n/a n/a n/a n/a Case report of a patient receiving an oral medication VC
medication error report intravenously related to the use of a parenteral syringe
analysis—avoiding inadvertent instead of an oral syringe.
intravenous injection of oral liquids;
medication within intravenous tubing
may be overlooked; searching by drug
name gives information on wrong
drug. Hosp Pharm. 2012;47(11):825-
828.
229 Shenoi AN, Fortenberry JD, Kamat P. Case Report n/a n/a n/a n/a Propofol was administered into an arterial line instead of VC
Accidental intra-arterial injection of an IV line.
propofol. Pediatr Emerg Care.
2014;30(2):136.
230 Ross MJ, Wise A. Accidental epidural Case Report n/a n/a n/a n/a Case report regarding the giving of IV medication into an VC
administration of Syntocinon. Int J epidural catheter.
Obstet Anesth. 2012;21(2):203-204.

Evidence Table
CONSENSUS SCORE
REFERENCE #

231 Kilcup M, Schultz D, Carlson J, Wilson Quasi-experimental 243 patients review group, Pharmacist medication No pharmacist Readmission rates, Medication reconciliation by pharmacists can save IIB
B. Postdischarge pharmacist 251 comparison group. reconciliation. medication medication money, discover medication discrepancies, and decrease
medication reconciliation: impact on reconciliation. discrepancies and hospital readmissions.
readmission rates and financial financial savings.
savings. J Am Pharm Assoc.
2013;53(1):78-84.
232 Ghatnekar O, Bondesson A, Persson Systematic Review w/ n/a Medication reconciliation Standard care Cost savings, Medication reconciliation decreases hospital IIB
U, Eriksson T. Health economic Meta-Analysis on admission and readmissions. readmissions and has an associated cost savings.
evaluation of the Lund Integrated discharge
Medicines Management model
(LIMM) in elderly patients admitted to
hospital. BMJ Open. 2013;3(1).
233 Feldman LS, Costa LL, Feroli ERJ, et al. Nonexperimental 563 patients n/a n/a Discrepancies between Reconciliation can prevent medication discrepancies and IIIB
Nurse-pharmacist collaboration on pre-admit and post it is cost effective.
medication reconciliation prevents admit medication
potential harm. J Hosp Med. orders.
2012;7(5):396-401.
234 Gimenez Manzorro A, Zoni AC, Quasi-experimental 1,823 prescriptions before, Implementation of an No electronic Unintended Medication reconciliation decreased the number of IIB
Rodriguez Rieiro C, et al. Developing a 1,958 prescriptions after. electronic medication medication medication unintended medication discrepancies.
programme for medication reconciliation tool. reconciliation tools. discrepancies.
reconciliation at the time of
admission into hospital. Int J Clin
Pharm. 2011;33(4):603-609.
235 Selcuk A, Sancar M, Okuyan B, Nonexperimental 133 patients age 65 and n/a n/a Potential for drug-drug Medication related problems and inappropriate IIIB
Demirtunc R, Izzettin FV. The older. interactions and medication utilization can be prevented by a pharmacist -
potential role of clinical pharmacists medication driven medication reconciliation and medication review
in elderly patients during hospital discrepancies. program.
admission. Pharmazie. 2015;70(8):559-
562.
236 Dodds LJ. Optimising pharmacy input Nonexperimental 3086 patients admitted to n/a n/a Discrepancies between Medication reconciliation identified medication IIIA
to medicines reconciliation at 30 acute care hospitals in medication history and discrepancies thereby improving medication safety.
admission to hospital: lessons from a England. medications ordered at
collaborative service evaluation of admission.
pharmacy-led medicines
reconciliation services in 30 acute
hospitals in England. Eur J Hosp
Pharm Sci Pract. 2014;21(2):95-101.

Evidence Table
CONSENSUS SCORE
REFERENCE #

237 Lee Y, Kuo L, Chiang Y, et al. Nonexperimental 3013 patients n/a n/a Medication The medication reconciliation program conducted by IIIA
Pharmacist-conducted medication discrepancies pharmacists was effective at finding medication
reconciliation at hospital admission discrepancies.
using information technology in
Taiwan. Int J Med Inf. 2013;82(6):522-
527.
238 Marotti SB, Kerridge RK, Grimer MD. RCT 118 patients to usual care, Medication history taken No history taken Number of omitted Medication reconciliation reduces the number of IB
A randomised controlled trial of 119 to medication history by pharmacist, Medication medications. omitted medications postoperatively.
pharmacist medication histories and taken, 120 to medication history and corrective
supplementary prescribing on history and prescribing by prescribing by pharmacist
medication errors in postoperative pharmacist
medications. Anaesth Intensive Care.
2011;39(6):1064-1070.
239 Mekonnen AB, McLachlan AJ, Brien Systematic Review w/ n/a n/a n/a n/a Pharmacist medication reconciliation during hospital IIB
JE. Effectiveness of pharmacist-led Meta-Analysis transitions decreases adverse drug related hospital
medication reconciliation revisits, all-cause readmissions and ED visits.
programmes on clinical outcomes at
hospital transitions: a systematic
review and meta-analysis. BMJ Open.
2016;6(2):e010003.
240 Becerra-Camargo J, Martinez- RCT 117 intervention group, Medication history taken No pharmacist Potential adverse drug Medication reconciliation by a pharmacist may IB
Martinez F, Garcia-Jimenez E. The 125 usual care group by pharmacist, interview events. contribute to reducing the risk of potential adverse drug
effect on potential adverse drug events.
events of a pharmacist-acquired
medication history in an emergency
department: a multicentre, double-
blind, randomised, controlled, parallel-
group study. BMC Health Serv Res.
2015;15:337.
241 Gattari TB, Krieger LN, Hu HM, Nonexperimental 69 patient charts n/a n/a Medication Medication discrepancies exist at the time of discharge IIIB
Mychaliska KP. Medication discrepancies at time from an inpatient pediatric unit.
discrepancies at pediatric hospital of discharge
discharge. Hosp Pediatr.
2015;5(8):439-445.

Evidence Table
CONSENSUS SCORE
REFERENCE #

242 Ziaeian B, Araujo KLB, Van Ness PH, Nonexperimental 377 patients n/a n/a Patient understanding Patients had very little or no knowledge of medication IIIB
Horwitz LI. Medication reconciliation of medication changes changes between admission and discharge, and
accuracy and patient understanding and accuracy of medication reconciliation needs to improve.
of intended medication changes on medication lists.
hospital discharge. J Gen Intern Med.
2012;27(11):1513-1520.
243 Wolf O, Aberg H, Tornberg U, Jonsson Nonexperimental 254 patients n/a n/a Number of medication There is a high number of discrepancies between the IIIB
KB. Do orthogeriatric inpatients have discrepancies. actual medications the patient is taking and the list
a correct medication list? A created upon admission to a hospital. A medication
pharmacist-led assessment of 254 reconciliation process can help to decrease the number
patients in a Swedish university of discrepancies.
hospital. Geriatr Orthop Surg Rehabil.
2016;7(1):18-22.
244 Yi SB, Shan JCP, Hong GL. Medication Nonexperimental Admission to facility n/a n/a Medication errors The most common errors found during reconciliation IIIC
reconciliation service in Tan Tock averaged 4,700 per included transcription errors and omissions.
Seng Hospital. Int J Health Care Qual monthly during study.
Assur. 2013;26(1):31-36.
245 González-García L, Salmerón-García Nonexperimental 176 patients n/a n/a Medication Medication reconciliation found several medication IIIB
A, García-Lirola M, Moya-Roldán S, discrepancies discrepancies.
Belda-Rustarazo S, Cabeza-Barrera J.
Medication reconciliation at
admission to surgical departments. J
Eval Clin Pract. 2016;22(1):20-25.
246 Hohn N, Langer S, Kalder J, Jacobs MJ, Nonexperimental 105 patients admitted for n/a n/a Medication Medication reconciliation found several medication IIIB
Marx G, Eisert A. Optimizing the vascular surgery discrepancies discrepancies.
pharmacotherapy of vascular surgery
patients by medication reconciliation.
J Cardiovasc Surg. 2014;55(2 Suppl
1):175-181.
247 Knez L, Suskovic S, Rezonja R, Nonexperimental 101 patients admitted to n/a n/a Medication Medication reconciliation found several medication IIIB
Laaksonen R, Mrhar A. The need for the hospital discrepancies discrepancies.
medication reconciliation: a cross-
sectional observational study in adult
patients. Respir Med. 2011;105(Suppl
1):S60-S66.

Evidence Table
CONSENSUS SCORE
REFERENCE #

248 Mendes AE, Lombardi NF, RCT 46 control group, 39 Medication reconciliation No medication Length of hospital stay Medication reconciliation is a good tool to discover IB
Andrzejevski VS, Frandoloso G, Correr intervention group and review reconciliation and medication discrepancies.
CJ, Carvalho M. Medication review
reconciliation at patient admission: a
randomized controlled trial. Pharm
Pract. 2016;14(1):656.
249 Holland DM. Interdisciplinary Nonexperimental 224 patients n/a n/a Medication Medication discrepancies were discovered during IIIB
collaboration in the provision of a discrepancies medication reconciliation.
pharmacist-led discharge medication
reconciliation service at an Irish
teaching hospital. Int J Clin Pharm.
2015;37(2):310-319.
250 Belda-Rustarazo S, Cantero-Hinojosa Nonexperimental 814 patients n/a n/a Medication Medication discrepancies were discovered during IIIB
J, Salmeron-Garcia A, Gonzalez-Garcia discrepancies medication reconciliation.
L, Cabeza-Barrera J, Galvez J.
Medication reconciliation at
admission and discharge: an analysis
of prevalence and associated risk
factors. Int J Clin Pract.
2015;69(11):1268-1274.
251 Bemt PMLA, Schrieck-de Loos EM, Quasi-experimental 1543 patients Pharmacist lead No medication Medication Medication reconciliation discovered several medication IIA
Linden C, Theeuwes AMLJ, Pol AG. medication reconciliation. reconciliation discrepancies discrepancies.
Effect of medication reconciliation on
unintentional medication
discrepancies in acute hospital
admissions of elderly adults: a
multicenter study. J Am Geriatr Soc.
2013;61(8):1262-1268.
252 Benson JM, Snow G. Impact of Quasi-experimental 1,650 orders pre Medication reconciliation No reconciliation Medication Medication reconciliation decreased the number of IIA
medication reconciliation on implementation, 1392 post on admission. discrepancies intentional and unintentional discrepancies.
medication error rates in community medications.
hospital cardiac care units. Hosp
Pharm. 2012;47(12):927-932.
253 Gao T, Gaunt MJ. Breakdowns in the Nonexperimental 501 medication error n/a n/a Error reports involving Medication reconciliation process should be IIIA
medication reconciliation process. reports medication standardized. The roles and responsibilities of personnel
Penn Patient Saf Advis. reconciliation. involved in reconciliation should be clearly defined. A
2013;10(4):125-136. standardized medication reconciliation form with a
scripted list of questions or prompts should be used.

Evidence Table
CONSENSUS SCORE
REFERENCE #

254 Rubio CB, Garrido PN, Segura BM, Nonexperimental 192 patients n/a n/a Discrepancies between Medication reconciliation should be performed. IIIB
Ferrit MḾ, Calderón AC, Catalá PRM. pre-admit and post
Medication reconciliation at admit medication
admission in old patients. Aten Farm. orders.
2014;16(1):13-22.
255 Gaspar Carreño M, Gavião Prado C, Nonexperimental 113 patients n/a n/a Medication Medication discrepancies are discovered during the IIIB
Costa Nogueira J, et al. Medication discrepancies process of reconciliation.
reconciliation on admission. Aten
Farm. 2014;16(4):273-281.
256 Hellstrom LM, Bondesson A, Hoglund Nonexperimental 670 patients n/a n/a Medication Discrepancies in the medication history were found IIIA
P, Eriksson T. Errors in medication discrepancies during medication reconciliation.
history at hospital admission:
prevalence and predicting factors.
BMC Clin Pharmacol. 2012;12:9.
257 Young L, Barnason S, Hays K, Do V. Quasi-experimental 100 medical records pre Nurse practitioner led Nurse led medication Medication Medication discrepancies decreased when medication IIB
Nurse practitioner-led medication and post intervention. medication reconciliation reconciliation without discrepancies reconciliation is used.
reconciliation in critical access using standardized standardized protocol
hospitals. J Nurse Pract. protocol and forms. or forms.
2015;11(5):511-518.
258 Bell CM, Brener SS, Gunraj N, et al. Nonexperimental 187,912 admissions, n/a n/a Long term medications Patients admitted to a hospital are at a high risk of IIIB
Association of ICU or hospital 208,468 control group not restarted within 90 having long term medications not continued therefore a
admission with unintentional days of discharge process of reconciliation should occur.
discontinuation of medications for
chronic diseases. JAMA.
2011;306(8):840-847.
259 Magalhães GF, Santos GN, Rosa MB, Nonexperimental 58 patients n/a n/a Medication Medication discrepancies were detected during IIIB
Noblat Lde A. Medication discrepancies medication reconciliation and the pharmacist was able
reconciliation in patients hospitalized to assist in resolving many of the discrepancies.
in a cardiology unit. PLoS One.
2014;9(12):e115491.

Evidence Table
CONSENSUS SCORE
REFERENCE #

260 Hellstrom LM, Hoglund P, Bondesson Quasi-experimental 1216 patients in admission Medication reconciliation No medication Number of ED visits, Performing medication reconciliation and medication IIA
A, Petersson G, Eriksson T. Clinical group, 2758 patients in and review. reconciliation and mortality, or re- review did not decrease the number of ED visits,
implementation of systematic control group. review. hospitalizations. mortality, or re-hospitalizations.
medication reconciliation and review
as part of the Lund Integrated
Medicines Management
model—impact on all-cause
emergency department revisits. J Clin
Pharm Ther. 2012;37(6):686-692.
261 Lehnbom EC, Stewart MJ, Manias E, Systematic Review n/a n/a n/a n/a Medication reconciliation has not demonstrated IIIB
Westbrook JI. Impact of medication significant improvements in patient outcomes.
reconciliation and review on clinical
outcomes. Ann Pharmacother.
2014;48(10):1298-1312.
262 Cortelyou-Ward K, Swain A, Yeung T. Expert Opinion n/a n/a n/a n/a IT systems should be used to decrease ADE's and that VB
Mitigating error vulnerability at the more research be performed especially on the elderly
transition of care through the use of population.
health IT applications. J Med Syst.
2012;36(6):3825-3831.
263 Treiber LA, Jones JH. Medication Nonexperimental 16 perioperative nurses n/a n/a Medication errors Medication errors are made in all phases of IIIB
errors, routines, and differences perioperative care.
between perioperative and non-
perioperative nurses. AORN J.
2012;96(3):285-294.
264 Gallo E, Pugi A, Lucenteforte E, et al. Nonexperimental 478 patients n/a n/a Patients taking herbal 49.8% of patients were taking an herbal remedy. IIIA
Pharmacovigilance of herb-drug remedies
interactions among preoperative
patients. Altern Ther Health Med.
2014;20(2):13-17.
265 Lee A, Varma A, Boro M, Korman N. Quasi-experimental 513 Medical record only, Medical record review plus No interview Medication More medication discrepancies were identified when the IIB
Value of pharmacist medication 986 medical record plus patient interview. discrepancies reconciliation process included a review of the medical
interviews on optimizing the interview. record and a patient interview compared to reviewing
electronic medication reconciliation only the medical record.
process. Hosp Pharm. 2014;49(6):530-
538.

Evidence Table
CONSENSUS SCORE
REFERENCE #

266 Meyer C, Stern M, Woolley W, Nonexperimental 315 patients n/a n/a Medication Patients did not supply an accurate medication history. IIIB
Jeanmonod R, Jeanmonod D. How discrepancies
reliable are patient-completed
medication reconciliation forms
compared with pharmacy lists? Am J
Emerg Med. 2012;30(7):1048-1054.
267 Lu Y, Clifford P, Bjorneby A, et al. Organizational 1893 patients discharged Medication reconciliation No medication Medication-related A medication reconciliation process should occur at VB
Quality improvement through Experience to nursing home in control at discharge. reconciliation readmission. discharge.
implementation of discharge order group, 87 intervention
reconciliation. Am J Health Syst group.
Pharm. 2013;70(9):815-820.
268 Richards M, Ashiru-Oredope D, Chee Nonexperimental 62 patients taking one or n/a n/a Medication Medication reconciliation identifies various types of IIIB
N. What errors can be identified by more medications upon discrepancies medication errors.
pharmacy-led medicines admission to a hospital.
reconciliation? A prospective study.
Acute Med. 2011;10(1):18-21.
269 Karapinar-Carkit F, Borgsteede SD, Nonexperimental 262 adult patients n/a n/a Medication costs and The process of medication reconciliation saved the IIIB
Zoer J, Egberts TCG, van den Bemt labor costs facility money.
PMLA, van Tulder M. Effect of
medication reconciliation on
medication costs after hospital
discharge in relation to hospital
pharmacy labor costs. Ann
Pharmacother. 2012;46(3):329-338.
270 Philbrick AM, Harris IM, Schommer JC, Nonexperimental 500 patients n/a n/a Discrepancies in Medication reconciliation reveals medication IIIB
Fallert CJ. Medication discrepancies medications discrepancies in medications taken by the patient and
associated with subsequent those prescribed or not prescribed.
pharmacist-performed medication
reconciliations in an ambulatory
clinic. J Am Pharm Assoc.
2015;55(1):77-80.
271 Leguelinel-Blache G, Arnaud F, Bouvet Nonexperimental 394 patients in pre and Reconciliation No reconciliation Medication Medication reconciliation found several medication IIIB
S, et al. Impact of admission post implementation discrepancies discrepancies.
medication reconciliation performed groups.
by clinical pharmacists on medication
safety. Eur J Intern Med.
2014;25(9):808-814.

Evidence Table
CONSENSUS SCORE
REFERENCE #

272 Mekonnen AB, McLachlan AJ, Brien Systematic Review w/ n/a n/a n/a n/a Medication reconciliation found several medication IIA
JE. Pharmacy-led medication Meta-Analysis discrepancies especially at admission and discharge.
reconciliation programmes at hospital
transitions: a systematic review and
meta-analysis. J Clin Pharm Ther.
2016;41(2):128-144.
273 Deitelzweig S. Care transitions in Literature Review n/a n/a n/a n/a Medication reconciliation and patient education should VB
anticoagulation management for occur at transition of care.
patients with atrial fibrillation: an
emphasis on safety. Ochsner J.
2013;13(3):419-427.
274 Zoni AC, Duran Garcia ME, Jimenez Quasi-experimental 80 patients pre- Admission medication No medication Medication Unintended medication discrepancies were decreased IIC
Munoz AB, Salomon Perez R, Martin intervention, 82 patients reconciliation reconciliation discrepancies after implementing a medication reconciliation process.
P, Herranz Alonso A. The impact of post-intervention.
medication reconciliation program at
admission in an internal medicine
department. Eur J Intern Med.
2012;23(8):696-700.
275 Andreoli L, Alexandra J, Tesmoingt C, Nonexperimental 170 patients, 1,515 Medication reconciliation No reconciliation Medication Medication reconciliation decreased the number of IIIB
et al. Medication reconciliation: a medications on admission discrepancies intentional and unintentional discrepancies.
prospective study in an internal
medicine unit. Drugs Aging.
2014;31(5):387-393.
276 Cornu P, Steurbaut S, Leysen T, et al. Nonexperimental 681 patients n/a n/a Discrepancies in Medication reconciliation performed at all transitions of IIIB
Effect of medication reconciliation at medication histories on care is an intervention to assist with preventing
hospital admission on medication admission and on medication discrepancies.
discrepancies during hospitalization discharge
and at discharge for geriatric patients.
Ann Pharmacother. 2012;46(4):484-
494.
277 Shiu JR, Fradette M, Padwal RS, et al. Nonexperimental 433 patients n/a n/a Medication Medication discrepancies continued to occur after IIIB
Medication discrepancies associated discrepancies medication reconciliation was preformed but all were
with a medication reconciliation considered to have no effect on the patient.
program and clinical outcomes after
hospital discharge. Pharmacotherapy.
2016;36(4):415-421.

Evidence Table
CONSENSUS SCORE
REFERENCE #

278 Lee KP, Hartridge C, Corbett K, Qualitative 7 attending physicians, 14 n/a n/a Defining who is Who is responsible for medication reconciliation needs IIIB
Vittinghoff E, Auerbach AD. “Whose residents, 35 nurses, 22 responsible for to be clearly defined.
job is it, really?” Physicians’, nurses’, pharmacists medication
and pharmacists’ perspectives on reconciliation.
completing inpatient medication
reconciliation. J Hosp Med.
2015;10(3):184-186.
279 De Winter S, Vanbrabant P, Spriet I, et Quasi-experimental 260 patients Use of standardized tool Interview only without Discrepancies found at The number of medication discrepancies is reduced IIA
al. A simple tool to improve use of tool reconciliation. when a standardized medication history questionnaire is
medication reconciliation at the used
emergency department. Eur J Intern
Med. 2011;22(4):382-385.
280 Cullinan S, O’Mahony D, Byrne S. Nonexperimental 123 patients n/a n/a Discrepancies in Use of a structured history of mediation use tool IIIB
Application of the structured history medication histories resulted in increased accuracy when compared to the
taking of medication use tool to taken by usual usual interview process.
optimise prescribing for older patients methods and taken
and reduce adverse events. Int J Clin using a structured tool.
Pharm. 2016;38(2):374-379.
281 Henneman EA, Tessier EG, Nathanson Quasi-experimental 50 patients pre, 50 Implementation of a No structured tool Medication The accuracy of the medication history improved when a IIA
BH, Plotkin K. An evaluation of a patients post structured tool discrepancies structured tool was used.
collaborative, safety focused, nurse-
pharmacist intervention for improving
the accuracy of the medication
history. J Patient Saf. 2014;10(2):88-
94.
282 Narendra PL, Biradar PA, Rao AN. Case Report n/a n/a n/a n/a Syringes and bowls containing medication on the sterile VC
Vanishing bowl of local anesthetics: a field should be labeled.
lesson for sterile labeling. Anesth
Essays Res. 2014;8(3):407-409.
283 Medication safety. J Pharm Pract Res. Case Report n/a n/a n/a n/a Medication errors were related to name mix-ups. VC
2015;45(1):86-92.
284 Guideline for sterile technique. In: Guideline n/a n/a n/a n/a Guideline detailing the principles for aseptic technique in IVA
Guidelines for Perioperative Practice. the operating room.
Denver, CO: AORN, Inc; 2017:75-104.
285 Or CKL, Wang H. A comparison of the Nonexperimental 40 engineering students, n/a n/a Name differentiation Tall man lettering significantly improved differentiation IIIB
effects of different typographical 40 pharmacy students accuracy accuracy between look-alike medications but other
methods on the recognizability of typographic styles also improved differentiation accuracy
printed drug names. Drug Saf. and should be considered.
2014;37(5):351-359.

Evidence Table
CONSENSUS SCORE
REFERENCE #

286 Sakuma M, Ida H, Nakamura T, et al. Nonexperimental 1189 pediatric patients n/a n/a Adverse drug events The rate of adverse drug events in Japan was similar to IIIA
Adverse drug events and medication the rate in the western countries and most drug errors
errors in Japanese paediatric occur during ordering and monitoring. Interventions to
inpatients: a retrospective cohort improve medication safety should focus on these two
study. BMJ Qual Saf. 2014;23(10):830- phases.
837.
287 Standards for perioperative nursing. Guideline n/a n/a n/a n/a Standards of perioperative practice which provide IVC
In: Guidelines for Perioperative guidelines for perioperative practice.
Practice. Denver, CO: AORN, Inc;
2015:693-708.
288 Cohen MR, Smetzer JL. ISMP Case Report n/a n/a n/a n/a Patients should be monitored after receiving VC
medication error report medications according to healthcare organization policy.
analysis—fatal patient-controlled
anesthesia adverse events; name
confusion with new cancer drugs;
medication safety officer group to
become a part of ISMP. Hosp Pharm.
2013;48(9):715-724.
289 Guideline for care of the patient n/a n/a n/a n/a IVC
receiving local anesthesia. In:
Guidelines for Perioperative Practice.
Denver, CO: AORN, Inc; 2017:617- Guideline for perioperative care of the patient receiving
628. Guideline local anesthesia.
290 Pfeifer K, Slawski B, Manley A, Nelson Organizational 461 pre, 147 post phase 1, n/a n/a n/a Patient compliance is improved with the use of a VA
V, Haines M. Improving preoperative Experience 143 post phase 2. standardized, electronically produced preoperative
medication compliance with medication instruction sheet.
standardized instructions. Minerva
Anestesiol. 2016;82(1):44-49.
291 Chien HY, Ko JJ, Chen YC, et al. Study Nonexperimental 102 people who disposed n/a n/a Reasons for not taking People discard their medications because they are not IIIB
of medication waste in Taiwan. J Exp of medications at a the medication. aware of proper storage conditions and how to use their
Clin Med. 2013;5(2):69-72. collection site. medications.
292 Warle-van Herwaarden MF, Kramers Guideline n/a n/a n/a n/a Medication guidelines of the Dutch HARM-Wrestling IVB
C, Sturkenboom MC, van den Bemt Task Force.
PMLA., De Smet PAGM; Dutch HARM-
Wrestling Task Force. Targeting
outpatient drug safety:
recommendations of the Dutch
HARM-wrestling task force. Drug Saf.
2012;35(3):245-259.

Evidence Table
CONSENSUS SCORE
REFERENCE #

293 Manworren RCB, Gilson AM. CE: Expert Opinion n/a n/a n/a n/a Patients should be provided with education on taking VB
Nurses’ role in preventing prescription medications only as prescribed, medications should be
opioid diversion. Am J Nurs. taken only by the person for whom they were
2015;115(8):34-40. prescribed, medication security, and disposal.
294 Strauch KA. Invisible pollution: the Expert Opinion n/a n/a n/a n/a Various medications or their derivatives are present in VB
impact of pharmaceuticals in the the environment. Patients should be educated about
water supply. AAOHN J. proper disposal methods of unused medications.
2011;59(12):525-533.
295 Trovato JA, Tuttle LA. Oral Organizational 42 patients receiving oral n/a n/a Oral chemotherapy Patients should receive education regarding proper VA
chemotherapy handling and storage Experience chemotherapy at a VA medication handling, medication administration.
practices among veterans affairs facility. storage, and disposal
oncology patients and caregivers. J practices.
Oncol Pharm Pract. 2014;20(2):88-92.
296 Perks S, Robertson S, Haywood A, Nonexperimental Clozapine tablets Storage in controlled room Storage in accelerated Physical characteristics Patients should be educated regarding the proper IIIB
Glass B. Clozapine repackaged into temperature conditions. conditions. and chemical stability handling/storage conditions of medications.
dose administration aids: a common of the medication.
practice in Australian hospitals. Int J
Pharm Pract. 2012;20(1):4-8.
297 Beckett VL, Tyson LD, Carroll D, Nonexperimental 277 care givers n/a n/a Accuracy of Patients should be instructed on the correct use of IIIB
Gooding NM, Kelsall AW. Accurately measurement measuring devices when administering medications.
administering oral medication to
children isn’t child’s play. Arch Dis
Child. 2012;97(9):838-841.
298 Armor BL, Wight AJ, Carter SM. Nonexperimental 43 patients n/a n/a Medication To facilitate the process of medication reconciliation a IIIB
Evaluation of adverse drug events and discrepancies list of medications that the patient is to be taking should
medication discrepancies in be provided to the patient at discharge.
transitions of care between hospital
discharge and primary care follow-up.
J Pharm Pract. 2016;29(2):132-137.

Evidence Table
CONSENSUS SCORE
REFERENCE #

299 Sarangarm P, London MS, Snowden Quasi-experimental 139 control, 140 Pharmacist education at No education Hospital readmission, Pharmacist patient discharge education improved IIB
SS, et al. Impact of pharmacist intervention. discharge. patient satisfaction and medication adherence and patient satisfaction.
discharge medication therapy medication adherence.
counseling and disease state
education: pharmacist assisting at
routine medical discharge (project
PhARMD). Am J Med Qual.
2013;28(4):292-300.
300 Valente S, Murray LP. Creative Organizational 340 patients and 278 new n/a n/a n/a The accuracy of patient reported allergies on their VB
strategies to improve patient safety: Experience nurses medical records increased after receiving an educational
allergies and adverse drug reactions. J flyer on the significance of accurate reporting and nurses
Nurses Staff Dev. 2011;27(1):E1-E5. reported more adverse drug events or reactions after
education on the significance of reporting of these
events.
301 Borgsteede SD, Karapinar-Carkit F, Qualitative 21 usual care, 10 Consultation regarding No Consultation Amount of information Medication counselling should combine verbal and IIIB
Hoffmann E, Zoer J, van den Bemt intervention group medications desired. written instructions, and be tailored to the patient’s
PMLA. Information needs about needs.
medication according to patients
discharged from a general hospital.
Patient Educ Couns. 2011;83(1):22-28.
302 Bouraoui S, Brahem A, Tabka F, Nonexperimental 20 nurses in both control n/a n/a Cellular DNA damage The group that handled chemotherapeutic agents had IIIB
Mrizek N, Saad A, Elghezal H. and experimental groups more cellular DNA damage than the control group.
Assessment of chromosomal
aberrations, micronuclei and
proliferation rate index in peripheral
lymphocytes from Tunisian nurses
handling cytotoxic drugs. Environ
Toxicol Pharmacol. 2011;31(1):250-
257.
303 Connor TH, Lawson CC, Polovich M, Systematic Review n/a n/a n/a n/a Health care workers who are exposed to IIIB
McDiarmid MA. Reproductive health chemotherapeutic agents seems to raise the risk of
risks associated with occupational congenital malformations, miscarriage and subfertility.
exposures to antineoplastic drugs in Precautions should be taken.
health care settings: a review of the
evidence. J Occup Environ Med.
2014;56(9):901-910.

Evidence Table
CONSENSUS SCORE
REFERENCE #

304 El-Ebiary AA, Abuelfadl AA, Sarhan NI. Nonexperimental 20 nurses, 18 pharmacists n/a n/a Genome damage Genome damage is found in nurses and pharmacists who IIIB
Evaluation of genotoxicity induced by handle chemotherapy medications therefore
exposure to antineoplastic drugs in precautions need to be taken including regular
lymphocytes of oncology nurses and biomonitoring.
pharmacists. J Appl Toxicol.
2013;33(3):196-201.
305 Gomez-Olivan LM, Miranda-Mendoza Nonexperimental 30 nurses in both control n/a n/a Oxidative stress The levels of oxidative stress biomarkers were elevated IIIB
GD, Cabrera-Galeana PA, et al. and experimental group. biomarkers in nurses who handle chemotherapeutic medications.
Oxidative stress induced in nurses by
exposure to preparation and handling
of antineoplastic drugs in Mexican
hospitals: a multicentric study. Oxid
Med Cell Longev. 2014;2014:858604.
306 Hon C, Abusitta D. Causes of health Qualitative 18 health care workers n/a n/a Reasons for exposure Many exposures to antineoplastic medications are IIIB
care workers’ exposure to who were exposed to to antineoplastic preventable if proper precautions are followed.
antineoplastic drugs: an exploratory antineoplastic medications medication.
study. Can J Hosp Pharm.
2016;69(3):216-223.
307 Musak L, Smerhovsky Z, Halasova E, Nonexperimental 249 nurses exposed to n/a n/a Presence of structural The nurses exposed to antineoplastic medications had IIIB
et al. Chromosomal damage among antineoplastic chromosomal more chromosomal aberrations than the nonexposed
medical staff occupationally exposed medications, 250 aberrations. individuals.
to volatile anesthetics, antineoplastic nonexposed individuals.
drugs, and formaldehyde. Scand J
Work Environ Health. 2013;39(6):618-
630.
308 Hon C, Teschke K, Shen H, Demers PA, Nonexperimental 201 health care workers n/a n/a Level of The levels of a chemotherapeutic medication was higher IIIB
Venners S. Antineoplastic drug cyclophosphamide in those who did not receive education on safe handling
contamination in the urine of compared to those who received the education.
Canadian healthcare workers. Int Arch
Occup Environ Health. 2015;88(7):933-
941.

Evidence Table
CONSENSUS SCORE
REFERENCE #

309 Controlling occupational exposure to Regulatory n/a n/a n/a n/a OSHA regulations covering the handling of hazardous n/a
hazardous drugs. Occupational Safety medications.
and Health Administration.
https://www.osha.gov/SLTC/hazardo
usdrugs/controlling_occex_hazardous
drugs.html. Accessed July 13, 2017.
310 Gulten T, Evke E, Ercan I, Evrensel T, Nonexperimental 9 nurses who administer n/a n/a Amount of genotoxicity Nurses exposed to antineoplastic medications lack IIIB
Kurt E, Manavoglu O. Lack of antineoplastic medications evidence of genotoxicity if PPE is worn and
genotoxicity in medical oncology using proper precautions, recommended technical equipment is used.
nurses handling antineoplastic drugs: 9 nurses from same unit
effect of work environment and who do not administer
protective equipment. Work. antineoplastic
2011;39(4):485-489. medications, 10 nurses
from other units.
311 Occupational Safety and Health Regulatory n/a n/a n/a n/a OSHA regulations covering hazardous medications. n/a
Administration. 29 CFR §1910.1200.
Hazard communication. US
Government Publishing Office.
http://www.ecfr.gov/cgi-bin/text-
idx?SID=3a88b79bbd5ccb9689a55025
239c3ff8&mc=true&node=se29.6.191
0_11200&rgn=div8. Accessed July 13,
2017.
312 Easty AC, Coakley N, Cheng R, et al. Guideline n/a n/a n/a n/a Canadian guidelines for administration of IVB
Safe handling of cytotoxics: guideline chemotherapeutic medications.
recommendations. Curr Oncol.
2015;22(1):e27-e37.
313 Hazardous drugs—handling in Guideline n/a n/a n/a Expert opinion and The recommendations address the precautions to be IVC
healthcare settings (800). In: USP research based taken when handling hazardous medications.
Compounding Compendium. guideline for handling
Rockville, MD: US Pharmacopeial hazardous
Convention; 2016:86-103. medications.

Evidence Table
CONSENSUS SCORE
REFERENCE #

314 Bussieres J, Tanguay C, Touzin K, Nonexperimental 12 measurement sites n/a n/a Environmental Periodic surface contamination should be performed IIIA
Langlois E, Lefebvre M. Environmental within each of 25 hospitals contamination with when using cyclophosphamide, ifosfamide, and
contamination with hazardous drugs cyclophosphamide, methotrexate to measure the effectiveness of current
in Quebec hospitals. Can J Hosp ifosfamide, and practices.
Pharm. 2012;65(6):428-435. methotrexate.
315 Ensuring healthcare worker safety Position Statement n/a n/a n/a n/a Recommendations for health care organizations to IVB
when handling hazardous drugs. institute when hazardous drugs are present.
Oncol Nurs Forum. 2015;42(3):217-
218.
316 Boiano JM, Steege AL, Sweeney MH. Qualitative 241 nurses, 183 pharmacy n/a n/a Knowledge of Nurses and pharmacists do not have adequate education IIIB
Adherence to precautionary practitioners standards on handling on handling antineoplastic medications.
guidelines for compounding antineoplastic
antineoplastic drugs: a survey of medications.
nurses and pharmacy practitioners. J
Occup Environ Hyg. 2015;12(9):588-
602.
317 Lawson CC, Rocheleau CM, Whelan Nonexperimental 7,482 female nurses n/a n/a Spontaneous abortion There is an increased risk of spontaneous abortion when IIIA
EA, et al. Occupational exposures after being exposed to exposed to antineoplastic medications.
among nurses and risk of chemotherapeutic
spontaneous abortion. Am J Obstet medication.
Gynecol. 2012;206(4):327.e1-327.e8.
318 Leduc-Souville B, Bertrand E, Schlatter Nonexperimental 568 hazardous situation n/a n/a Hazardous situations Personnel need education on the proper handling of IIIB
J. Risk management of excreta in a based on exposure to excreta from patients who are receiving hazardous
cancer unit. Clin J Oncol Nurs. excreta from patients medications. Policies and procedures on handling of
2013;17(3):248-252. receiving hazardous hazardous drugs should be adopted. Personnel should
medications. take precautions including wearing of PPE when handling
hazardous drugs.
319 Meade E. Avoiding accidental Literature Review n/a n/a n/a n/a Summation review of guidelines for handling of VA
exposure to intravenous cytotoxic hazardous medications.
drugs. Br J Nurs. 2014;23(16):S34.
320 Vyas N, Yiannakis D, Turner A, Sewell Expert Opinion n/a n/a n/a n/a Evidence based report of precautions to take when VB
GJ. Occupational exposure to anti- handling chemotherapeutic medications.
cancer drugs: a review of effects of
new technology. J Oncol Pharm Pract.
2014;20(4):278-287.

Evidence Table
CONSENSUS SCORE
REFERENCE #

321 Villarini M, Dominici L, Piccinini R, et Nonexperimental 52 health care workers n/a n/a Presence of primary, There is less primary DNA damage when personal IIIB
al. Assessment of primary, oxidative involved in preparation, oxidative and excision protective equipment is used.
and excision repaired DNA damage in transportation, repaired DNA damage.
hospital personnel handling administration and
antineoplastic drugs. Mutagenesis. disposal of anticancer
2011;26(3):359-369. agents.
322 Menonna-Quinn D. Safe handling of Expert Opinion n/a n/a n/a n/a Evidence based guidance for handling chemotherapeutic VB
chemotherapeutic agents in the medications.
treatment of nonmalignant diseases. J
Infus Nurs. 2013;36(3):198-204.
323 PB70: Liquid Barrier Performance and Guideline n/a n/a n/a n/a Guideline describing the levels of barrier protection for IVC
Classification of Protective Apparel gowns.
and Drapes Intended for use in Health
Care Facilities. Arlington, VA:
Association for the Advancement of
Medical Instrumentation; 2012.
324 Occupational Safety and Health Regulatory n/a n/a n/a n/a OSHA requirements for respiratory protection. n/a
Administration. 29 CFR §1910.134.
Respiratory protection.
https://www.osha.gov/pls/oshaweb/
owadisp.show_document?p_table=st
andards&p_id=12716. Accessed July
13, 2017.
325 Hon C, Teschke K, Chua P, Venners S, Nonexperimental 275 surface samples taken n/a n/a Contamination of Surfaces were found to be contaminated by IIIB
Nakashima L. Occupational exposure at drug delivery, drug surface chemotherapeutic medications from the time of delivery
to antineoplastic drugs: identification preparation, transport and until waste disposal.
of job categories potentially exposed drug administration states
throughout the hospital medication of the hospital medication
system. Saf Health Work. system.
2011;2(3):273-281.

Evidence Table
CONSENSUS SCORE
REFERENCE #

326 Hon C, Teschke K, Chu W, Demers P, Nonexperimental 229 surfaces n/a n/a Contamination of Surfaces were found to be contaminated by IIIB
Venners S. Antineoplastic drug surface chemotherapeutic medications from the time of delivery
contamination of surfaces throughout until waste disposal.
the hospital medication system in
Canadian hospitals. J Occup Environ
Hyg. 2013;10(7):374-383.
327 Queruau Lamerie T, Nussbaumer S, Nonexperimental Laboratory study n/a n/a Effectiveness of Various cleaning agents were more effective than others IIIB
Decaudin B, et al. Evaluation of cleaning agent but effectiveness of each agent varied with the
decontamination efficacy of cleaning contaminate.
solutions on stainless steel and glass
surfaces contaminated by 10
antineoplastic agents. Ann Occup Hyg.
2013;57(4):456-469.
328 Walton AML, Mason S, Busshart M, et Organizational n/a n/a n/a n/a Quality project which reviewed the literature regarding VB
al. Safe handling: implementing Experience precautions to take when working with
hazardous drug precautions. Clin J chemotherapeutic medications.
Oncol Nurs. 2012;16(3):251-254.
329 Bohlandt A, Groeneveld S, Fischer E, Nonexperimental Four cleaning agents used n/a n/a Presence of Cleaning procedures should be adapted to the IIIB
Schierl R. Cleaning efficiencies of on wood laminate, glass, antineoplastic medication and to the surface type.
three cleaning agents on four stainless steel, medications on
different surfaces after contamination polyvinylchloride surfaces after cleaning.
by gemcitabine and 5-fluorouracile. J intentionally contaminated
Occup Environ Hyg. 2015;12(6):384- with 5-flourouracile and
392. gemcitabine.
330 Schierl R, Novotna J, Piso P, Bohlandt Nonexperimental 151 wipe samples during n/a n/a Presence of platinum. If careful precautions are followed the levels of platinum IIIB
A, Nowak D. Low surface 19 procedures. are small and safe.
contamination by cis/oxaliplatin
during hyperthermic intraperitoneal
chemotherapy (HIPEC). Eur J Surg
Oncol. 2012;38(1):88-94.

Evidence Table
CONSENSUS SCORE
REFERENCE #

331 Couch J, Burr G, Niemeier MT. Expert Opinion n/a n/a n/a n/a Report of a simulated surgical procedure involving the VA
Evaluation of exposures to healthcare use of cicplatin and lists precautions to take.
personnel from cisplatin during a
mock interperitoneal operation for
cancer treatment. J Assoc Occup
Health Prof Healthc. 2011;31(2):17-
19.
332 Solid Waste Disposal Act [as amended Regulatory n/a n/a n/a n/a Lists actions to be taken by generators of hazardous n/a
through Pub L No 107-377, December waste.
31, 2002].
333 Souza Oliveira AD, CÃ¢mara Alves AE, Systematic Review n/a n/a n/a n/a Nurses need education on the hazards of handling IIIB
Silva JA, Silva Oliveira LF, Medeiros hazardous medications.
SM. Occupational risks of the nursing
team’s exposure to chemotherapeutic
agents: integrative literature review.
Rev Enferm UFPE. 2013;7(3):794-802.
334 Hennessy KA, Dynan J. Improving Organizational n/a n/a n/a n/a Educational material delivered in various ways increased VB
compliance with personal protective Experience compliance with wearing of PPE during chemotherapy
equipment use through the model for administration.
improvement and staff champions.
Clin J Oncol Nurs. 2014;18(5):497-500.
335 Boiano JM, Steege AL, Sweeney MH. Nonexperimental 2069 health care n/a n/a Compliance with Education on the risks of handling antineoplastic IIIB
Adherence to safe handling guidelines professionals administered safety practices while medications is needed because of a low rate of
by health care workers who antineoplastic handling adherence to safety practices.
administer antineoplastic drugs. J medications. chemotherapeutic
Occup Environ Hyg. 2014;11(11):728- agents.
740.
336 Jeong KW, Lee B, Kwon MS, Jang J. Nonexperimental 236 nurses n/a n/a Compliance with Nurses should receive education regarding handling anti IIIB
Safety management status among safety practices while cancer medications.
nurses handling anticancer drugs: handling
nurse awareness and performance chemotherapeutic
following safety regulations. Asian agents
Pac J Cancer Prev. 2015;16(8):3203-
3211.

Evidence Table
CONSENSUS SCORE
REFERENCE #

337 Polovich M, Gieseker KE. Expert Opinion n/a n/a n/a n/a Personnel working in non-oncology units such as surgery VA
Occupational hazardous drug need education on the safe handling of hazardous
exposure among non-oncology medications, patient's bodily wastes and clean-up.
nurses. Medsurg Nurs. 2011;20(2):79-
85.
338 Hon C, Teschke K, Demers PA, Nonexperimental 225 employees n/a n/a Presence of The hands of many health care workers who had no IIIB
Venners S. Antineoplastic drug antineoplastic direct contact with antineoplastic medications were
contamination on the hands of medications on the found to have the medication on their hands therefore
employees working throughout the hands all employees should be included in the medical
hospital medication system. Ann surveillance program.
Occup Hyg. 2014;58(6):761-770.
339 Hon C, Teschke K, Shen H. Health care Nonexperimental 120 employees n/a n/a Knowledge of Education on the risks associated with antineoplastic IIIA
workers’ knowledge, perceptions, and standards on handling medications is needed by all disciplines working in the
behaviors regarding antineoplastic antineoplastic facility.
drugs: survey from British Columbia, medications
Canada. J Occup Environ Hyg.
2015;12(10):669-677.
340 Ladeira C, Viegas S, Padua M, et al. Nonexperimental 27 nurses with exposure to n/a n/a Presence of The frequency of micronuclei was greater in the samples IIIB
Assessment of genotoxic effects in chemotherapeutic micronuclei in the of those who were exposed to chemotherapeutic agents
nurses handling cytostatic drugs. J medication, 111 participants blood. and the levels were greater in those who were older.
Toxicol Environ Health A. 2014;77(14- unexposed individuals
16):879-887.
341 Santovito A, Cervella P, Delpero M. Nonexperimental 20 nurses who handle n/a n/a Presence of The nurses exposed to antineoplastic medications had IIIB
Chromosomal damage in peripheral antineoplastic chromosomal more chromosomal aberrations than the nonexposed
blood lymphocytes from nurses medications, 20 people not aberrations. individuals therefore medical surveillance should be
occupationally exposed to chemicals. exposed to antineoplastic performed.
Hum Exp Toxicol. 2014;33(9):897-903. medications.
342 Drug Enforcement Administration Regulatory n/a n/a n/a n/a Regulatory requirements for disposing controlled n/a
(DEA), Department of Justice. medications.
Disposal of controlled substances.
Final rule. Fed Regist.
2014;79(174):53519-53570.

Evidence Table
CONSENSUS SCORE
REFERENCE #

343 Unused Pharmaceuticals in the Health Expert Opinion n/a n/a n/a n/a Statement from the EPA describing methods and VB
Care Industry: Interim Report. regulations that cover the disposal of medications.
Washington, DC: Environmental
Protection Agency; 2008.
https://nepis.epa.gov/Exe/ZyPDF.cgi/
P100165B.PDF?Dockey=P100165B.PD
F. Accessed July 13, 2017.
344 Federal Water Pollution Control Act Regulatory n/a n/a n/a n/a Controls what types of waste may be placed into n/a
[as amended through Pub L No 107- waterways
303, November 27, 2002].
345 Chiarello M, Minetto L, Giustina SVD, Nonexperimental 100 Liters of hospital n/a n/a Presence of Medication or medication byproducts were found in IIIB
Beal LL, Moura S. Popular waste water. medication or hospital wastewater.
pharmaceutical residues in hospital medication
wastewater: quantification and byproducts.
qualification of degradation products
by mass spectroscopy after treatment
with membrane bioreactor. Environ
Sci Pollut Res Int. 2016;23(16):16079-
16089.
346 Frédéric O, Yves P. Pharmaceuticals in Nonexperimental Samples of wastewater n/a n/a Presence of Pharmaceuticals are found in various amounts in IIIC
hospital wastewater: their ecotoxicity from a previous study. medications in hospital wastewater.
and contribution to the wastewater.
environmental hazard of the effluent.
Chemosphere. 2014;115(1):31-39.
347 Nguyen H, Pham H, Vo D, et al. The Quasi-experimental 516 IV medication doses Training program No training provided Clinically relevant Clinically relevant errors decreased after the training. IIB
effect of a clinical pharmacist-led pre, 688 medication doses errors.
training programme on intravenous post.
medication errors: a controlled
before and after study. BMJ Qual Saf.
2014;23(4):319-324.

Evidence Table
CONSENSUS SCORE
REFERENCE #

348 Laukaityte E, Bruyere M, Bull A, Case Report n/a n/a n/a n/a Medication errors can be prevented by all participants VC
Benhamou D. Accidental injection of having adequate education.
patent blue dye during gynaecological
surgery: lack of knowledge
constitutes a system error. Anaesth
Crit Care Pain Med. 2015;34(1):57-60.
349 Westbrook JI, Rob MI, Woods A, Parry Nonexperimental 568 intravenous n/a n/a Medication Education is needed to help prevent medication errors. IIIB
D. Errors in the administration of medication administration errors
intravenous medications in hospital administrations
and the role of correct procedures
and nurse experience. BMJ Qual Saf.
2011;20(12):1027-1034.
350 Karavasiliadou S, Athanasakis E. An Literature Review n/a n/a n/a n/a Nurses should receive education regarding medication VB
inside look into the factors error prevention in all related phases of the medication
contributing to medication errors in use process.
the clinical nursing practice. Health Sci
J. 2014;8(1):32-44.
351 Zyoud AH, Abdullah NAC. The effect Qualitative 255 Jordanian RNs from n/a n/a Impact on individual The researchers recommend Jordanian nurses receive IIIB
of individual factors on the three public hospitals conditions (eg level of more education on mathematical calculations and
medication error. Glob J Health Sci. knowledge on medication administration process.
2016;8(12):57756. calculation) on
medication errors.
352 Thornton P. Medication safety. J Case Report n/a n/a n/a n/a Education is needed to help prevent medication errors. VC
Pharm Pract Res. 2015;45(4):450-458.
353 Niemann D, Bertsche A, Meyrath D, et Nonexperimental 14 student nurses and 23 1. 3 page handout Number of errors Medication errors All three on the interventions to decrease medication IIIB
al. A prospective three-step licensed nurses working in containing information on before the instituting related to handling of administration errors described should be implemented.
intervention study to prevent a pediatric unit in medication handling; 2. 60 the project and after medications.
medication errors in drug handling in Germany. Medication minute training course on instituting each step.
paediatric care. J Clin Nurs. 2015;24(1- administrations: Baseline - medication handling
2):101-114. 581, Intervention 1 - 400 guidelines and background
Intervention 2 - 498 information; 3. 56 page
Intervention 3 - 441 comprehensive reference
book.

Evidence Table
CONSENSUS SCORE
REFERENCE #

354 Samaranayake NR, Cheung STD, Chui Nonexperimental 1538 medication errors n/a n/a Errors related to The reported technology related medication errors were IIIB
WCM, Cheung BMY. Technology- reported from Jan. 2006 to technology. socio-technical errors or device errors. Socio-
related medication errors in a tertiary December 2010 with 263 technological errors are errors that resulted from human
hospital: a 5-year analysis of reported being technology-related. interaction with technology. The researchers
medication incidents. Int J Med recommend that the end users be educated on the use
Inform. 2012;81(12):828-833. of technology and that the process be continuously
monitored.
355 Hicks RW, Hernandez J, Wanzer LJ. Expert Opinion n/a n/a n/a n/a Patients and the perioperative team need education on VB
Perioperative pharmacology: patient- the functionality of PCA pumps.
controlled analgesia. AORN J.
2012;95(2):255-262.
356 Speroni KG, Fisher J, Dennis M, Daniel Nonexperimental 123 nurses n/a n/a Near-misses Education should be provided for nurses regarding IIIB
M. What causes near-misses and how techniques to avoid and handle near-misses incidents.
are they mitigated?. Nursing.
2013;43(4):19-24.
357 Abbotoy JL, Sessanna L. Hands-on Expert Opinion n/a n/a n/a n/a Describes an education plan for use of bar-code VC
BCMA education for direct care medication administration.
nurses. Nurs Manage. 2012;43(11):15-
18.
358 Cleary-Holdforth J, Leufer T. The Expert Opinion n/a n/a n/a n/a Education of nurses has a significant role in decreasing VB
strategic role of education in the medication errors.
prevention of medication errors in
nursing: part 2. Nurse Educ Pract.
2013;13(3):217-220.
359 Leufer T, Cleary-Holdforth J. Let’s do Expert Opinion n/a n/a n/a n/a Nurses must be educated to reduce medication errors. VB
no harm: medication errors in
nursing: part 1. Nurse Educ Pract.
2013;13(3):213-216.
360 Lu M, Yu S, Chen I, Wang KK, Wu H, RCT 112 nurses intervention PowerPoint presentation No presentations Number of correct Pharmacology education strengthens nurses knowledge IB
Tang F. Nurses’ knowledge of high- group, 113 nurses control on high-alert medications answers regarding high- on high-alert medications which may reduce medication
alert medications: a randomized group alert medication exam. errors.
controlled trial. Nurse Educ Today.
2013;33(1):24-30.
361 Gokhman R, Seybert AL, Phrampus P, Nonexperimental 186 medication n/a n/a Medication errors There is a need for education to prevent medication IIIA
Darby J, Kane-Gill SL. Medication administrations errors during emergency situations. Tracking errors
errors during medical emergencies in during emergency situations should occur.
a large, tertiary care, academic
medical center. Resuscitation.
2012;83(4):482-487.

Evidence Table
CONSENSUS SCORE
REFERENCE #

362 Lap FT, Tak KY, So Yuen AS. How to Qualitative 269 nurses n/a n/a Nurses behaviors Nurses should have continuing education on medication IIIB
change nurses’ behavior leading to during medication administration as a means to decrease medication
medication administration errors administration. errors.
using a survey approach in United
Christian Hospital. J Nuse Educ Pract.
2014;4(12):17-26.
363 Sears K, Goodman WM. Risk factors Nonexperimental 372 surveys n/a n/a Self reported Lack of training contribute to both the number of IIIB
for increased severity of paediatric medication errors. medication errors and the severity of the errors.
medication administration errors.
Healthc Policy. 2012;8(1):e109-e126.
364 Abbasinazari M, Zareh-Toranposhti S, Quasi-experimental 200 medication Medication administration No education Intravenous Nurses need education on intravenous medication IIB
Hassani A, Sistanizad M, Azizian H, administrations before and education medication preparation and administration.
Panahi Y. The effect of information 200 after education. preparation and
provision on reduction of errors in administration errors.
intravenous drug preparation and
administration by nurses in ICU and
surgical wards. Acta Med Iran.
2012;50(11):771-777.
365 Haw C, Stubbs J, Dickens G. Medicines Qualitative 50 nurses in a psychiatric n/a n/a Correct evaluation and Education on medication processes is needed and can be IIIB
management: an interview study of hospital responses to vignettes delivered by the use of vignettes.
nurses at a secure psychiatric covering medication
hospital. J Adv Nurs. 2015;71(2):281- administration.
294.
366 Haseeb A, Winit-Watjana W, Bakhsh Quasi-experimental Pre-intervention: 660 Education of all disciplines No education Use of high risk The use of high risk abbreviations decreased after an IIB
AR, et al. Effectiveness of a handwritten physician involved with medications. abbreviations. educational session by a pharmacist on the appropriate
pharmacist-led educational orders, medication use of abbreviations.
intervention to reduce the use of high- administration records,
risk abbreviations in an acute care and pharmacy dispensing
setting in Saudi Arabia: a quasi- sheets from 482 patients.
experimental study. BMJ Open. Post-intervention: 498
2016;6(6):e011401. handwritten physician
orders, medication
administration records,
and pharmacy dispensing
sheets from 388 patients.

Evidence Table
CONSENSUS SCORE
REFERENCE #

367 Chedoe I, Molendijk H, Hospes W, Quasi-experimental 20 patients pre, 22 Medication error No education Number of medication An education program on frequent medication IIB
Van den Heuvel ER, Taxis K. The effect patients post prevention education errors. administration and preparations resulted in fewer
of a multifaceted educational medication errors.
intervention on medication
preparation and administration errors
in neonatal intensive care. Arch Dis
Child Fetal Neonatal Ed.
2012;97(6):F449-F455.
368 Lohmann K, Ferber J, Haefeli MF, et Nonexperimental 373 nurses, 75 physicians n/a n/a Perceived uncertainties Additional education is needed for the nursing staff on IIIC
al. Knowledge and training needs of in medication unsuitable drugs for patients with dysphagia or feeding
nurses and physicians on unsuitable administration. tubes.
drugs for patients with dysphagia or
feeding tubes. J Clin Nurs. 2015;24(19-
20):3016-3019.
369 Keane K. Reducing medication errors Expert Opinion n/a n/a n/a n/a Nurses must be trained on the use of the technology. VC
by educating nurses on bar code
technology. Medsurg Nurs. 2014;23(5
Suppl 1):10-11.
370 Alsulami Z, Choonara I, Conroy S. Qualitative 48 nurses n/a n/a Adherence to the Education on the double-checking process may increase IIIB
Nurses’ knowledge about the double- double checking nurses adherence to the process.
checking process for medicines process.
administration. Nurs Child Young
People. 2014;26(9):21-26.
371 Dabliz R, Levine S. Medication safety Expert opinion n/a n/a n/a n/a Summarizes recommendations for contents of reference VC
in neonates. Am J Perinatol. materials.
2012;29(1):49-56.
372 Implementing real-time point of care Organizational 35 nurses pre, 25 nurses Education on benefits of No education Medication errors Medication errors were reduced with the use of real VB
documentation: a QI project to Experience post. and the expectations time point of care documentation.
address medication administration around point of care
errors. Online J Nurs Inform. documentation.
2014;18(3):1-1.
373 Bucsi R. Documentation errors related Case Report n/a n/a n/a n/a Medication errors in an office setting were related to VB
to electronic health records. Insight. incorrect entry of medications into electronic medical
2012;37(3):19. record.
374 Order scanning systems (and fax Case Report n/a n/a n/a n/a Case report of orders not being received by pharmacy VC
machines) may pull multiple pages because of multiple pages being fed through fax machine
through the scanner at the same time, at one time.
leading to drug omissions. Alta RN.
2011;67(1):24-25.

Evidence Table
CONSENSUS SCORE
REFERENCE #

375 Perez-Garcia MdC, Soria-Aledo V, Organizational 20 units in a hospital. n/a n/a n/a A quality improvement program is useful in detecting VB
Collantes F. Implementation and Experience safety problems and corrective measures can be
evaluation of the medication instituted without additional cost.
management in nursing units of a
university hospital by means of a
quality improvement cycle. Appl Nurs
Res. 2016;29:148-156.
376 Nwasor EO, Sule ST, Mshelia DB. Qualitative 43 anesthesia n/a Medication errors Fifty six percent of the respondents admitted to making IIIC
Audit of medication errors by professionals in Nigeria a medication error at some time during their career. The
anesthetists in north western Nigeria. researchers recommend that a mechanism for reporting
Niger J Clin Pract. 2014;17(2):226-231. should be in place in every facility.
377 Burch KJ. Using a trigger tool to assess Nonexperimental 60 charts n/a n/a Adverse drug events Use of a trigger tool discovered adverse drug events that IIIC
adverse drug events in a children’s were not reported through a voluntary reporting
rehabilitation hospital. J Pediatr program.
Pharm Ther. 2011;16(3):204-209.
378 Carnevali L, Krug B, Amant F, et al. Nonexperimental 240 admissions n/a n/a Adverse drug events Use of a trigger tool discovered adverse drug events that IIIB
Performance of the adverse drug were not previously reported.
event trigger tool and the global
trigger tool for identifying adverse
drug events: experience in a Belgian
hospital. Ann Pharmacother.
2013;47(11):1414-1419.
379 Nobre C, McKay C. Surveillance of Expert Opinion n/a n/a n/a n/a Using a trigger tool is an effective way to identify and VB
adverse drug events in a large tertiary- quantify potential adverse drug events.
care hospital. Conn Med.
2012;76(2):91-94.
380 Harkanen M, Kervinen M, Ahonen J, Nonexperimental 463 patient records n/a n/a Adverse drug events Trigger tools are an efficient method for identifying IIIC
Voutilainen A, Turunen H, Vehvilainen- adverse drug events.
Julkunen K. Patient-specific risk
factors of adverse drug events in
adult inpatients—evidence detected
using the global trigger tool method. J
Clin Nurs. 2015;24(3-4):582-591.

Evidence Table
CONSENSUS SCORE
REFERENCE #

381 Kung K, Carrel T, Wittwer B, Engberg Nonexperimental 119 nurses MESRT reporting system Usual reporting system Number of reported The chosen method of self reporting of medication error IIIB
S, Zimmermann N, Schwendimann R. medication errors reporting was more effective at catching medication
Medication errors in a Swiss errors than the existing medication error report.
cardiovascular surgery department: a
cross-sectional study based on a
novel medication error report
method. Nurs Res Pract.
2013;2013:671820.
382 Donaldson N, Aydin C, Fridman M, Nonexperimental Medications administered n/a n/a Medication errors Direct observation is an effective tool to use for IIIB
Foley M. Improving medication to 8,594 patients. determining medication errors.
administration safety: using naive
observation to assess practice and
guide improvements in process and
outcomes. J Healthc Qual.
2014;36(6):58-68.
383 Taghon T, Elsey N, Miler V, McClead Organizational n/a n/a n/a n/a A hybrid system of reporting adverse drug events should VB
R, Tobias J. A medication-based Experience be implemented.
trigger tool to identify adverse events
in pediatric anesthesiology. Jt Comm J
Qual Patient Saf. 2014;40(7):326-334.
384 Erstad BL, Patanwala AE, Theodorou Systematic Review n/a n/a n/a n/a A multimodal approach should be used for identifying IIIB
AA. Comparison of methods for the medication errors.
detection of medication safety events
in the critically ill. Curr Drug Saf.
2012;7(3):238-246.
385 Davies K, Mitchell C, Coombes I. The Organizational 209 nurses pre and post. n/a n/a Ability to correctly Direct observation with immediate feedback improves VB
role of observation and feedback in Experience perform steps of performance medication administration tasks.
enhancing performance with medication
medication administration. J Law administration process.
Med. 2015;23(2):316-321.
386 Elliott P, Martin D, Neville D. Quasi-experimental 205 employees Electronic system Paper system Number of error An increase of medication error reporting occurred after IIB
Electronic clinical safety reporting reports. the implementation of an electronic error reporting
system: a benefits evaluation. JMIR system.
Med Inform. 2014;2(1):e12.

Evidence Table
CONSENSUS SCORE
REFERENCE #

387 Meyer-Massetti C, Cheng CM, Systematic Review n/a n/a n/a n/a The four medication safety assessment methodologies IIIB
Schwappach DLB, et al. Systematic (eg, review of incident reports, review of charts, direct
review of medication safety observation, trigger tools) all have strengths and
assessment methods. Am J Health weaknesses.
Syst Pharm. 2011;68(3):227-240.
388 Cronrath P, Lynch TW, Gilson LJ, et al. Quasi-experimental 84 failure points Iniation of healthcare No healthcare failure Over sedation Recommends using a healthcare failure mode effect IIB
PCA oversedation: application of failure mode effect mode effect analysis analysis process to address system improvements and
healthcare failure mode effect analysis process process ensure patient safety.
(HFMEA) analysis. Nurs Econ.
2011;29(2):79-87.
389 Velez-Diaz-Pallares M, Delgado- Quasi-experimental 8703 prescriptions before, Implementation of a No computerized Medication error The use of healthcare failure mode effect analysis lead IIB
Silveira E, Carretero-Accame ME, 10,248 after computerized prescriber prescriber order entry reports. to identification of actions aimed at reducing medication
Bermejo-Vicedo T. Using healthcare implementation order entry system. system. errors.
failure mode and effect analysis to
reduce medication errors in the
process of drug prescription,
validation and dispensing in
hospitalised patients. BMJ Qual Saf.
2013;22(1):42-52.
390 Curatolo N, Gutermann L, Devaquet Nonexperimental 91 patients n/a n/a n/a The use of the Plan, Do, Study, Act cycle was successfully IIIB
N, Roy S, Rieutord A. Reducing used to implement and maintain a medication
medication errors at admission: 3 reconciliation process.
cycles to implement, improve and
sustain medication reconciliation. Int J
Clin Pharm. 2014;37(1):113-120.
391 Ashley L, Dexter R, Marshall F, Organizational 8 member chemotherapy n/a n/a n/a The use of the Failure Mode, and Effects Analysis VB
McKenzie B, Ryan M, Armitage G. Experience team assisted in identifying several specific chemotherapy
Improving the safety of failure modes.
chemotherapy administration: an
oncology nurse-led failure mode and
effects analysis. Oncol Nurs Forum.
2011;38(6):E436-E444.
392 Cheng C, Chou C, Wang P, Lin H, Kao Organizational 8,310 before Implementation of a n/a n/a Healthcare failure mode effect analysis is a useful tool VB
C, Su C. Applying HFMEA to prevent Experience implementation, 10,162 computerized order entry for evaluating potential risks for adverse events and
chemotherapy errors. J Med Syst. after. system. computerized prescriber order entry systems may be
2012;36(3):1543-1551. used to decrease medication errors.

Evidence Table
CONSENSUS SCORE
REFERENCE #

393 Nguyen C, Cote J, Lebel D, et al. The Organizational 2 nursing units with an n/a n/a Causes of medication A failure mode, effects and criticality analysis process is VB
AMELIE project: Failure mode, effects Experience average daily census of 27. adverse events during an effective method to identify and prioritize
and criticality analysis: a model to drug administration. interventions to be taken to decrease medication errors.
evaluate the nurse medication
administration process on the floor. J
Eval Clin Pract. 2013;19(1):192-199.
394 Beckett RD, Yazdi M, Hanson LJ, Nonexperimental 45 health systems n/a n/a Presence of safety The researchers recommend the use of quality metrics IIIA
Thompson RW. Improving medication metrics, and the which apply to each individual facility and that the
safety through the use of metrics. J reporting venue. metrics be clear, transferable into an intervention, and
Pharm Pract. 2014;27(1):61-64. be reported to all venues to which the metric applies.
395 de Boer M, Ramrattan MA, Boeker Nonexperimental 252 medical records n/a n/a Adverse drug events Using a set of quality is an effective way to identify and IIIB
EB, Kuks PFM, Boermeester MA, Lie-A- quantify adverse drug events.
Huen L. Quality of pharmaceutical
care in surgical patients. PLoS One.
2014;9(7):e101573.
396 Smeulers M, Verweij L, Maaskant JM, Systematic Review n/a n/a n/a n/a Quality indicators centered on medication safety need to IIIB
et al. Quality indicators for safe be individualized to the practice setting.
medication preparation and
administration: a systematic review.
PLoS One. 2015;10(4):e0122695.
397 Rodriguez-Gonzalez CG, Martin- Expert Opinion n/a n/a n/a n/a Recommends a process for quality analysis. VB
Barbero ML, Herranz-Alonso A, et al.
Use of failure mode, effect and
criticality analysis to improve safety in
the medication administration
process. J Eval Clin Pract.
2015;21(4):549-559.
398 Miller DF, Fortier CR, Garrison KL. Bar Nonexperimental 548,405 scanned n/a n/a Nursing and pharmacy Nursing and pharmacy work arounds are present and IIIA
code medication administration medications workarounds. may decrease effectiveness of alert system therefore
technology: characterization of high- workflows must be continually reviewed.
alert medication triggers and clinician
workarounds. Ann Pharmacother.
2011;45(2):162-168.

Evidence Table
CONSENSUS SCORE
REFERENCE #

399 Rack LL, Dudjak LA, Wolf GA. Study of Qualitative 220 surveys; 6 focus n/a n/a Type of and reasons When a bar coding system is in place the RN staff IIIB
nurse workarounds in a hospital using groups consisting of 43 for technological work- administering medications use various workarounds to
bar code medication administration participants. arounds. avoid use of the technology. The workarounds were
system. J Nurs Care Qual. created because not enough outlets were available to
2012;27(3):232-239. charge the units, lack of education on what to do during
emergencies, and alterations in work flow reducing
efficiency. The researchers recommend that hospital
leaders understand the barriers that lead to
workarounds and take steps to prevent them.
400 Niazkhani Z, Pirnejad H, van der Sijs H, Qualitative 21 clinical end-users of the n/a n/a List of work-arounds Work arounds may help maintain a smooth workflow, IIIB
Aarts J. Evaluating the medication computerized order entry resulting from use of a but others may increase the time taken to administer
process in the context of CPOE use: system computerized order medications and may endanger patient safety.
the significance of working around entry system.
the system. Int J Med Inf.
2011;80(7):490-506.
401 Coleman JJ, Hodson J, Brooks HL, Organizational 2,121,765 medication n/a n/a n/a Sharing of information from a quality study on a VA
Rosser D. Missed medication doses in Experience doses dashboard appeared to help decrease missed
hospitalised patients: a descriptive medication doses.
account of quality improvement
measures and time series analysis. Int
J Qual Health Care. 2013;25(5):564-
572.
402 Munn Z, Scarborough A, Pearce S, et Quasi-experimental 1,500 medication Audit and feedback No feedback process Compliance with The use of an audit and feedback process improved IIB
al. The implementation of best administrations baseline process standards for compliance with best practices in medication
practice in medication administration and 827 medication medication administration.
across a health network: a multisite administrations during administration.
evidence-based audit and feedback follow-up.
project. JBI Database System Rev
Implement Rep. 2015;13(8):338-352.

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