Why Are There So Many Deaths Caused By Medical Errors and What Solutions Can Decrease Them?

Health Service Systems – HSM541
June 20 2015

Background
Medical errors kill at least 44,000 people and perhaps as many as 98,000 people per year. Or do they kill over 180,000 per year? Maybe even 440,000 people killed by medical errors? Allen (2013)
In 1999 the Institute of Medicine (IOM) published a report titled “To Err Is Human: Building A Safer Health System” that leveled the healthcare community. They reported that according to two studies “perhaps as many as 98,000 people die in hospitals each year as a result of medical errors that could have been prevented”. IOM (1999) Then the Office of Inspector General for Health and Human Services followed up with a report in 2010 that stated “bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year”. Allen (2013) And finally in 2013, the numbers were once again raised. Per a report from the Journal of Patient Safety that approximately “440,000 PAEs (preventable/potential adverse events) that contribute to the death of patients each year from care in hospitals. This is roughly one-sixth of all deaths that occur in the United States each year”. They are now the U.S.’s third leading cause of death, behind only heart disease and cancer.
All of the numbers mentioned in the first paragraph are medical errors that were “preventable”. Mistakes by the people you put your trust in killed you, not the reason why you were admitted to the hospital. Now understand they didn’t do it on purpose. But it happens.
Define the problem
Granted, a death by even one medical error is one too many, but why do the reports have such drastically different numbers? How in the world can “official” reports be off by approximately 400,000 deaths…per year? Who is in charge? The IOM? Office of Inspector General for the Department of Health and Human Services? Journal of Patient Safety? An advocacy group? The first two seem better suited than the last two.
Before we go any further, let’s define the terms used a great deal in this discussion - medical error, adverse event and preventable adverse event (PAE).
From IOM [report], medical error can be defined as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” IOM (1999) The NCBI explains a little bit more in layman’s terms as “mistakes, close calls, near misses, active errors, and latent errors.” NCBI (2002)
The NCBI report defines adverse events (or events) as “an injury caused by medical management rather than by the underlying disease or condition of the patient” (usually inferring harm was done to the patient) and a preventable adverse event as “an adverse event attributable to error is a preventable adverse event…A condition for which reasonable steps may reduce (but not necessarily eliminate) the risk of that complication occurring.” NCBI (2002)
A study by the University of Washington School of Medicine provides a graph that makes these three terms easier to understand and what is or is not counted as a medical error. All “potential AEs” (near misses) and preventable AEs are considered medical errors whereas only the “non-preventable AEs” were not considered medical errors:

University of Washington School of Medicine

Additionally, the term “adverse event” is included in almost every article discussing medical errors and since both medical errors and adverse events can and/or do cause harm to patients [and because everywhere you look there is a different definition of the two], this paper will use them interchangeably under the larger umbrella of medical errors, specifying between them when necessary.
And then we’ll take a look at some solutions that could be widely implemented with as little impact on operations as possible when it comes to reducing the number of medical errors. With so many dying of medical errors every year it will take not just one solution, but an amalgamation of solutions to effectively lower the annual number of deaths. The short answer as to why there are so many deaths is that so many things can go wrong: wrong drug, wrong dose, misuse of medical equipment, miscommunication, hurried/overworked/tired staff…and a myriad of other reasons. And with approximately 1.2 billion ambulatory care visits (physician offices, hospital outpatient and emergency departments only) annually in the U.S. alone, you can easily see that if just a fraction were part of an error, it would add up quickly. CDC (2014)
This problem won’t go away, nor should any reasonable person think it will. There will always be medical errors. What with all the people (doctor, nurse, pharmacist, etc.), places (inpatient, outpatient, follow-up locations, etc.) and things (pharmacy, equipment, etc.) involved, you could argue the fact that there should be more medical errors than what the reports detail!
Literature Review
Propublica posted an article that is very robust in explaining medical errors, what the correct annual numbers really are (essentially “updates” to the numbers in the 1999 IOM report) and cites several other doctors, including a doctor who is referred to as the “father of patient safety” and was on the committee that wrote the “To Error Is Human” IOM report. Propublica (2013) Based on the one issue that (I’d like to see explained further) comes from the American Hospital Association (AHA) stating they have more confidence in the IOM’s 98,000 [number than the other studies numbers that have derived 180,000 / 210,000 / 440,000] deaths caused by medical errors. The author of the article doesn’t provide any theories on why the AHA, a very prominent player in these numbers, doesn’t put value in the other numbers, but of course, you would think they agree with the lower estimate as they are tightly integrated with the individuals who are/will be tasked to lower the number – the providers.
Some information is just plain confusing and exhaustive. An 81-page report by the Department of HHS’ Office of Inspector General looks very inclusive and immensely detailed…although that may be the problem. OIG (2010) They point out things such as “Retroperitoneal hemorrhage secondary to anticoagulant (warfarin)” when it relates to excessive bleeding. First, I’m sure this report mattered to people stuck in the red tape of Washington, but how does this bloated, confusing report help the public? Are doctors expected to pick up a copy of this report, read it and make adjustments when better communication, washing of hands, more sleep, etc., would fix a number of errors? And I found this report from clicking a link on the Journal of Participatory Medicine website that stated this OIG report “found up to 180,000 deaths annually attributable to medical error.” Windrum (2013) I searched this report for that number, but failed to find it. Again, to make these reports better and have a greater impact on the public at large would be ideal if I didn’t have to find the specific numbers that added up to 180,000 in the report. This website just confuses the fact when including this link. A very hard read of no value to me.
The Journal of Patient Safety took a look at updated estimates from “modern studies published from 2008 to 2011.” James (2013) This site sourced 4 studies that used a Global Trigger Tool (GTT) to identify certain data within medical records “such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient.” The Global Trigger Tool, a product of the Institute for Healthcare Improvement (IHI), includes “a list of known AE triggers as well as instructions for selecting records, training information, and appendices with references and common questions” for finding AEs within Electronic Medical Records (EMRs). IHI (2015) This all sounds great until the article also explains that “public health researchers have established that only 10 to 20 percent of errors are ever reported and, of those, 90 to 95 percent cause no harm to patients.” This statement could be misleading as the article doesn’t clarify if, with no more than 20% of errors being reported and more than 90% not causing harm, are we underreporting medical errors? Is the 440,000 number low? It would have been nice for them to explain just a bit more when reporting this data.

The website Health Affairs compared “three methods to detect adverse events in hospitalized patients…and found that the adverse event detection methods commonly used to track patient safety in the United States today - voluntary reporting and the Agency for Healthcare Research and Quality’s Patient Safety Indicators - fared very poorly compared to other methods and missed 90 percent of the adverse events.” Health Affairs (2011) Repeat. Missed 90% of the adverse events!! However, in that same report, the third detection method they used - the Global Trigger Tool - found “at least ten times more confirmed serious events than these other methods. Overall, adverse events occurred in one-third of hospital admissions.” Which is a good thing. At least the GTT is leading to more discoveries of these events for possible solutions down the road. The authors go on to state that “voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the US health care system and misdirect efforts to improve patient safety”, which we discuss in the next Literature Review section. So that throws a big wrench into this. Are they saying that, even with missing 90% of the adverse events, we’re still near the 440,000 number? Or if that number would be higher if every healthcare facility used the GTT? Confusing.
Using the Global Trigger Tool sounds like a great, quick way to comb through electronic medical records looking for adverse events until you investigate into its weaknesses (and weakness, in general, in finding the “true” number of medical errors). First and foremost, the EMR is only as good as the data being entered into it and the data is only as good as the people who are doing the entering. And if a doctor knows how the Global Trigger Tool works, the possibility exists that they can “fudge” data to make the adverse event look non-existent to the tool. In addition, not every medical facility is electronic so this tool can’t assist paper users and the overall medical error numbers would have to rely on [honest] human reporting. The week of September 24, 2013 the CEO of Leapfrog Group Leah Binder “criticized hospitals for failing to report PAEs accurately and failing to ‘put a priority on safety.’" The Advisory Board Company (2013) This maintains that finding medical errors requires a cumulative, honest effort, although the Global Trigger Tool is a great start, but relies exclusively on data entered into the patient’s medical record.
One of the possible solutions to getting the number of medical errors correct, and thereby helping to decrease them, was approached in an article by Pacific Standard. Allen (2014) The very first line of this article gets things started by stating that we are doing enough to track and prevent medical errors and without tracking, how do we know how bad we are and how do we know if we’re improving. That type of data would be very valuable and they are spot on to point this out. To improve it, we have to measure it. Also their call for Congress to take more action could at least attract some federal money. Some of the experts also called on the CDC to begin tracking medical errors in addition to the data they track already. Each of these ideas could result in fewer errors and would provide a lot of value towards diminishing the number of medical errors…but implementing multiple proposals would have the biggest impact…albeit expensive to do.
Part of the AHRQ’s (Agency for Healthcare Research and Quality) mission is to “produce evidence to make health care safer…to make sure that the evidence is understood and used.” AHRQ (2014) On their website is a number of ideas a patient can do to help with in a feature called “20 Tips to Help Prevent Medical Errors”. This is different because the AHRQ writes this for the patient and not for the medical community. Ideas include bringing all of your medications to your doctor visits, asking all health care workers who will touch you whether they have washed their hands and making sure that someone coordinates your care. AHRQ (2014) This is terrific as it suggests that people take control of their health and healthcare choices thereby helping to reduce the number of medical errors. While this is great, what person outside of healthcare knows about the AHRQ, what it does and how it can help decrease medical errors? For that matter, how many people outside of the healthcare industry know there are so many medical errors? Although they have good ideas, being only one of 12 agencies within the Department of Health and Human Services doesn’t help. They’re buried in bureaucracy when it comes to helping individuals, so I’m not sure of the worth they bring to the layman.
In its original reporting, the IOM “estimated costs due to medical errors in the U.S. of approximately $37.6 billion per year. Of the $37.6 billion, about $17 billion are associated with preventable errors… updated estimates place costs for errors in hospitals nationwide to be between $17 billion and $29 billion each year.” RadPhysics (2015) Based on those numbers, at least we’re headed in the right direction which you could equate to less errors being made. But, that might not be correct assumption. Maybe less costly mistakes are being made, but still a lot of mistakes are occurring. The site leads you to thinking that much more needs to be done to decrease not only the costs associated with medical errors but the actual number of medical errors and that nobody should be satisfied until those numbers are negligible. Good site for the shear dollar amounts of what medical errors cost.
Provider handwashing is among the most common causes of medical errors, sometimes categorized under infection. Researchers at Chicago's Northwestern Memorial Hospital found out that when volunteers tapped a key contaminated with Methicillin-resistant Staphylococcus Aureus (MRSA), the bacteria transferred to their hands 92% of the time and Vancomycin - resistant enterococci (VRE) 50% of the time. Consumer Affairs (2005) That is critical. All the provider needs to do to help prevent this is lather their hands with soap and water for ~20 seconds and dry with a clean towel. CDC (2013) Or use an alcohol-based hand sanitizer prior to touching a patient. This website/research is impressive as I had no idea that MRSA could live on a keyboard…and with less paper in the hospital and more computers, this is a significant finding. More handwashing = less MRSA/VRE = less hospital-acquired infection(s) = less medical errors. The site was valuable in pointing out another way in which medical errors could be transmitted and reduced.
An article on the website exscribe links to a PowerPoint completed by the ONC for HIT titled “HIT Safety: Progress Made and Challenges Ahead” ONC (2014) and points out “Three times as many physicians reported that their EHR prevented a potential medication error than caused one” (slide 6) and that “Advanced EMR adoption leads to a 27% decline in all (aggregated) events and a 30% decline in medication events” (slide 18). These numbers are what you’re looking for (and they’re skewed towards IT adoption). This PowerPoint, although long at 73 slides, is easy to read, summarizes numbers/thoughts along the way and provides many examples. Very robust in data and therefore, very valuable.
Problem Analysis
The issue of medical errors and how to reduce them is robust. This is obvious when you look when the IOM report came out, 1999, and the fact that we still have a high number of medical errors. To be fair, there are many moving pieces and parts, so many different types of errors that can [and do] occur that multiple solutions need to be implemented to make significant progress. And also realizing that these “problems” will never completely go away. They can’t. Humans are involved. But they can be severely curtailed.
Regrettably, some of the causes of medical errors are common sense: a clinicians misinterpreted handwriting, confusing drug labels, poor communication (both provider to provider and provider to patient), long hours worked by the provider, number of patients seen per shift, increasing levels of admissions, etc. And there are many more than just what is mentioned here.
Answers to these are straightforward, but not when it comes to fundamentally implementing them. For example, you can’t just add more providers to lower the number of hours a provider works or to lower the patient/provider ratio. Lack of money severely limits what can be done, how quickly things can be done, in what order and how many solutions are implemented. And as the IOM report pointed out, there are many different types of errors IOM (1999) and below is a subset: Diagnostic – Error or delay in diagnosis, outmoded tests and failure to act on results Treatment – Errors…in a procedure, in administering treatment and in drug dosage Preventative – Failure to provide prophylactic treatment and inadequate follow-up Other – Failure of communication and equipment failure

For an example, let’s look at Adverse Drug Event. An adverse drug event is probably the most common medical error…also called a medication I. Per The National Coordinating Council for Medication Error Reporting and Prevention, a medication error is "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer...related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use." MedicineNet – Stoppler (2014) This is a long quote, but necessary. This points out that this is not only an issue with provider, but the patient is/can be at fault here also. If the patient doesn’t take his medication correctly (too much, in an incorrect combination with other drugs, etc.) the “error” falls on the patient. But the answer to this is also in the quote…education and monitoring. As the patient, if you don’t know or don’t understand, ask for clarification. If you don’t think you heard correctly, ask. Write it down. Have somebody with you for another set of ears to hear the instructions. However, sometimes it is the providers fault. Either way, it’s a medication error and by default a medical error. As you can see by all the different elements, one of the problems is that it’s just not “tell the Doctor to speak slower” because there are at least ten other things that could go wrong. The Doctor could do everything right and the patient does the harm to themselves. In summary, these medical errors are wide-ranging, not one area’s “fault” and require everything going as planned so as not be become a medical error.
Possible Solutions
Implementing an Electronic Medical Record and utilizing it to its fullest extent would allow for a full realization of the advantages an EMR brings to every part of a healthcare system and would assist a hospital in reducing medical errors . However, being more specific for possible solutions, and since it tops the list of medical errors (at least what’s being reported), we’ll start by addressing solutions to medicine errors. Keep in mind that there are inpatient medicine errors (committed while the patient is in the hospital) and outpatient medicine errors (taking the drugs home). Barcode Medication Administration (BCMA) creates a system of 5 “rights” to ensure safety: the right patient is receiving the right medication at the right time at the right dose via the right route. If any part of this doesn’t match up, for instance, if a particular drug at the bedside was never ordered for the patient, the clinician is alerted by the Electronic Medical Record and can refuse to administer to speaking with the doctor. If any one of these 5 is wrong but given to the patient anyway, it could cause a medical/medicine error on that patient. The drawbacks to implementing BCMA are cost, training/adoption and the manual overriding of alerts in the system.
BCMA won’t entirely prevent medication errors but could significantly reduce the number of them. There are still challenges to BCMA such as if the barcode scanner can’t read the barcode or if the clinician receives an error from the EMR but bypasses the error without much investigation as to why the error was received. Electronic prescribing (e-prescribing) of prescribed medications would be another solution to reduce the number of medical/medicine errors. Completed through the EMR, by electronically sending your prescription to your pharmacy, the patient can’t lose your prescription and it can’t be misread/misinterpreted by the pharmacist. Also, e-prescribing allows for drug/drug and drug/allergy interaction checking…which could generate even more medical errors if left unchecked. As with most technology in the healthcare setting, disadvantages are usually limited to a small, consistent group. With e-prescribing, weaknesses to implementation are similar to BCMA - cost, training/adoption and the manual overriding of alerts in the system. Better documentation could help reduce medical errors simply by utilizing the Electronic Medical Record for more inclusive, detailed information…not just a pain that doctors complete because “I’m required to do so I don’t get in trouble”. Typically called CPOE (for the clinicians – Computerized Physician Order Entry), decision support software is embedded within the EMR that includes not only the previously mentioned alerts/alarms, but also templates for documentation (which could mean all providers are collecting the necessary information), pre-built orders/order sets for easier, more precise ordering of meds and reference information for the provider, specific to where they are in the chart and what they’re trying to reference. Obstacles to better documentation, in relation to being electronic instead of on paper, resistance to give up [hand]writing, workflow issues and perceived “extra” work for providers.
Solution and Implementation
Coming up with solutions to implement is easy…but would require a long list, many knowledgeable people and a lot of time. In saying that, a healthcare system installing robust health care information technology systems, typically referred to as an EMR or EHR, would have the biggest impact on decreasing medical errors, assuming the hospital would, over time, install all of the pieces and parts that make safety a priority. In our examples above, two of them were specific to medication errors, so we’ll stick to that theme and choose Barcode Medication Administration (BCMA)…which is typically an “add-on” that can be attached to feed from and directly into an EMR without using the keyboard (which could introduce errors).
As stated above Barcode Medication Administration helps decrease medication errors by making sure the medication being administered is going to the right patient, receiving the right medication at the right time at the right dose via the right route. And it’s done by the nurse scanning a barcode on her badge, then scanning the barcode on the patient’s wristband and finally scanning the barcode on the medication via handheld scanner. All of the scans are aggregated by the computer system and checked against orders, medications, allergies, etc., in the EMR. Furthermore, management can run reports in the EMR to locate trouble spots such as personnel that excessively override the alarms, etc., with the BCMA.
Outlining several major steps for an implementation begins with the necessary buy-in from the C-level (which OKs the budget) and the major users of the system to ensure you have a staff that not only understands what BCMA is, but knows that it’s necessary for dispensing meds and understands that this will take training and practice. Next is evaluating/choosing your BCMA vendor. Usually it’s from the same vendor as your EMR, but may require some site visits to see what you would like to purchase/use as there are some different features among the competitors. It could be a case of your vendor not having the decision support you’re looking for or the types of alerts you’re expecting when an incorrect med is dosed. In addition, some vendors may only work wirelessly while others need to be connected to a laptop (COWs - Computer On Wheels). Next you would select your actual hardware (if given a choice) you’d want to work with your system. You also need to ensure your hospital network is robust enough to support your decision and, if needed, you have enough Computers On Wheels for the complete BCMA rollout. Schedule, train and implement!
Above is a very high-level overview of what needs to be done for a BCMA rollout. There are many things that are too in-the-weeds for this paper such as reviewing the budget, reviewing wristband selections, and more that support BCMA, timeline, etc.
Not all is peaches and cream with BCMA. There are issues, but as with everything that involves humans or technology, there always will be. Concerns with BCMA are items such as unreadable patient wristbands, missing hardware, low batteries on wireless handheld units, personnel overwriting error alerts, sketchy network connectivity and upfront costs. If staff takes a proactive approach to making BCMA work, everybody wins. Hardware will be placed back in the chargers, alerts aren’t overwritten, etc. The pros definitely outweigh the cons for using BCMA.
Justification
With the studies showing so many medical errors, there isn’t one easy fix. There will be numerous things that can and will be done to reduce these error numbers. One big thing that can make a difference would be the implementation of technology which helps with tracking and dispensing of medications…thereby curbing the medicine error numbers. Even as our course book writes that “most of our focus on adverse events relates to hospital-based care where medical and surgical procedures occur, a variety of potent drugs may be dispensed for many patients and the physical environment can encourage hospital-based infections.” Barton (2010)
Moreover, once Barcode Medication Administration is up and running, the healthcare organization can compare post-BCMA to pre-BCMA numbers to evaluate the effectiveness of the BCMA solution and where changes, training, etc., still need to be made. There are a number of positive studies related to installing BCMA such as one by the Official Journal of the Society for Academic Emergency Medicine, “Total Errors” (the sum of wrong dose, wrong drug errors etc.) fell over 81% after BMCA was installed. Bonkowski, Carnes, Melucci, Mirtallo, Prier, Reichert, Bruce and Weber (2013). Another study backs that up, stating that “emergency department accuracy rates increased from 86% before the system was implemented to 95% after 1 year of use, and from 87% to 99% when wrong-time errors were excluded from the analysis… BCMA-eMAR did not introduce new types of errors into the administration process… BCMA-eMAR and direct observation were also more effective at intercepting, recording, and preventing errors than was voluntary reporting”. Simone (2014) (eMar is another part of the EMR that automatically documents the administration of medication directly into the EMR). Everybody knows that the cost of an EMR implementation is high, not to mention add-ons such as Barcode Medication Administration. But then again, so is the cost of giving the wrong drug to somebody. Is the cost worth more than a human life? With today’s technology, we are still making too many medical errors. We need to grasp the advances of technology and use them to decrease the number of errors we are still seeing.
References
Allen, M (2013) How Many Die From Medical Mistakes in U.S. Hospitals? https://www.propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals Institute of Medicine (1999) To Err Is Human: Building A Safer Health System https://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf NCBI (2002), Measures of Patient Safety Based on Hospital Administrative Data - The Patient Safety Indicators. http://www.ncbi.nlm.nih.gov/books/NBK43847/

University of Washington School of Medicine, Errors Teaching Module: Talking About Harmful Medical Errors with Patients https://depts.washington.edu/toolbox/errors.html

Centers for Disease Control - CDC (2014) Ambulatory Care Use and Physician office visits http://www.cdc.gov/nchs/fastats/physician-visits.htm

Propublica (2013) How Many Die From Medical Mistakes in U.S. Hospitals? https://www.propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals

Department of Health and Human Services, Office of Inspector General (2010) Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries https://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf
Journal of Participatory Medicine – Windrum, B (2013) It’s Time to Account for Medical Error in “Top Ten Causes of Death” Charts http://www.jopm.org/opinion/commentary/2013/04/24/it%E2%80%99s-time-to-account-for-medical-error-in-%E2%80%9Ctop-ten-causes-of-death-charts/ James, John (2013) A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care http://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx Institute for Healthcare Improvement – IHI (2015) IHI Global Trigger Tool for Measuring Adverse Events http://www.ihi.org/resources/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.aspx Health Affairs – Classen, D, Resar, R, Griffin, F, Federico, F, Frankel, T, Kimmel, N, Whittington, J, Frankel, A, Seger, A & James, B (2011)
‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured http://content.healthaffairs.org/content/30/4/581.abstract The Advisory Board Company (2013) Medical errors may be the country's third-leading cause of death http://www.advisory.com/daily-briefing/2013/09/24/medical-errors-may-be-the-country-third-leading-cause-of-death Allen, Marshall (2014) We Need to Start Tracking Patient Harm and Medical Mistakes Now http://www.psmag.com/health-and-behavior/arent-tracking-patient-harm-86351 AHRQ (2014) Mission & Budget http://www.ahrq.gov/cpi/about/mission/index.html

AHRQ (2014) 20 Tops to Help Prevent Medical Errors http://www.ahrq.gov/patients-consumers/care-planning/errors/20tips/index.html

RadPhysics (2015) History of Medical Errors http://www.radphysics.com/history-of-medical-errors

Consumer Affairs (2005) Hospital Computer Keyboards Can Spread Germs, Study Finds https://www.consumeraffairs.com/news04/2005/hospital_keyboards.html

Centers for Disease Control and Prevention (2013) Washing Your Hands Stops MRSA http://www.cdc.gov/niosh/docs/2013-114/pdfs/2013-114.pdf

Office of the National Coodinator (2014) HIT Safety: Progress Made and Challenges Ahead http://healthit.gov/sites/default/files/ONC_HIT_SafetyHealthITWeekWebinar_2014_09_12.pdf MedicineNet – Stoppler, Melissa C (2014) The Most Common Medication Errors http://www.medicinenet.com/script/main/art.asp?articlekey=55234

Barton, Lindsey P. (2010) Understanding the U.S. Health Services System, pg 456.
Chicago, IL: Health Administration Press

Official Journal of the Society for Academic Emergency Medicine – Bonkowski, J, Carnes, C, Melucci, J, Mirtallo, J, Prier, B, Reichert, E, Moffat-Bruce, S & Weber, R (2013) Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors http://onlinelibrary.wiley.com/doi/10.1111/acem.12189/pdf Pharmacy Times – Simone, Aimee (2014) Barcoding Technology May Improve Medication Accuracy
http://www.pharmacytimes.com/news/barcoding-technology-may-improve-medication-accuracy