Toolkit References

  1. Institute for Safe Medication Practices Canada. A near miss involving cyclophosphamide. ISMPCanada Safety Bulletin [Internet] 2008 [cited 2015 Oct 7]; 8(7):1-2. Available from: http://ismp-canada.org/download/safetyBulletins/ISMPCSB2008-07CylophosphamideNearMiss.pdf
  2. Institute for Safe Medication Practices Canada. Insulin errors. ISMP Canada Safety Bulletin [Internet] 2003 [cited 2015 Oct 7]; 3(4):1-2. Available from: http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2003-04Insulin.pdf
  3. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance. 2nd ed. San Francisco: Jossey-Bass Publishers; 2009. Website: Associates in Process Improvement, www.apiweb.org
  4. Accreditation Canada. Required organizational practices handbook [Internet]. Ottawa, ON; 2016 [cited 2016 Jan 12]. Available from: http://accreditation.ca/sites/default/files/rop-handbook-2016-en.pdf
  5. Kuhn IF. Abbreviations and acronyms in healthcare: When shorter isn’t sweeter. Pediatric Nursing. 2007; 33(5):392-398.
  6. Sinha S, McDermott F, Srinivas G, Houghton PWJ. Use of abbreviations by healthcare professionals: What is the way forward? Postgraduate Medical Journal. 2011; 87(1029):450-452.
  7. Axelsson J, Elmstahl S. Home care aides in the administration of medications. International Journal for Quality in Health Care. 2004; 16(3):237-243.
  8. Jefferies D, Johnson M, Nicholls D. Nursing documentation: How meaning is obscured by fragmentary language. Nursing Outlook. 2011; 59(6):e6-e12.
  9. United Kingdom Department of Health. Essence of care 2010. Norwich: The Stationery Office; 2010 [cited 2015 Oct 7]. Available from: https://www.gov.uk/government/publications/essence-of-care-2010
  10. Isaac J. Good Samaritan Society Health Records Manager. Personal communication (phone). March 2014.
  11. Traynor K. Enforcement outdoes education at eliminating unsafe abbreviations. American Journal of Health-Systems Pharmacy. 2004; 61:1314, 1317, 1322.
  12. Brunetti L, Santell J, Hicks, R. The impact of abbreviations on patient safety. The Joint Commission Journal on Quality and Patient Safety. 2007; 33(9): 576-583.
  13. Dooley MJ, Wiseman M, Gu G. Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation. Internal Medicine Journal. 2012; 42(3):e19-e22.
  14. Abramson EL, Bates DW, Jenter C, Volk LA, Barron Y, Quaresimo J, Seger A, et al. Ambulatory prescribing errors among community-based providers in two states. Journal of the American Medical Informatics Association [Internet]. 2012 [cited 2015 Oct 7]; 19:644-648. http://jamia.oxfordjournals.org/content/19/4/644
  15. Institute for Safe Medication Practices Canada. Do not use dangerous abbreviations, symbols and dose designations [Internet]. 2006 [cited 2015 Oct 7]. Available from: http://www.ismp-canada.org/download/ISMPCanadaListOfDangerousAbbreviations.pdf
  16. Institute for Safe Medication Practices. ISMP’s list of error-prone abbreviations, symbols, and dose designations [Internet]. 2004 [cited 2015 Oct 7]. Available from: https://www.ismp.org/tools/errorproneabbreviations.pdf
  17. The Joint Commission. Facts about the official “do not use” list [Internet]. 2013 [cited 2015 Oct 7]. Available from: http://www.jointcommission.org/facts_about_do_not_use_list
  18. National Coordinating Council for Medication Error Reporting and Prevention. Dangerous abbreviations [Internet]. No date [cited 2015 Oct 7]. Available from: http://www.nccmerp.org/dangerous-abbreviations
  19. Australian Commission on Safety and Quality in Healthcare. Recommendations for terminology, abbreviations and symbols used in the prescribing and administration of medicines [Internet]. 2011 [cited 2015 Oct 7]. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/32060v2.pdf
  20. Institute for Safe Medication Practices. Eliminating dangerous abbreviations and dose expressions in the print and electronic world [Internet]. Medication Safety Alert Acute Care. 2002, February 20 [cited 2015 Oct 7]. Available from: http://www.ismp.org/newsletters/acutecare/articles/20020220.asp
  21. Institute for Healthcare Improvement. Science of improvement: Forming the team [Internet]. No date [cited 2015 Oct 7]. Available from: http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementFormingtheTeam.aspx
  22. Canadian Patient Safety Institute. Improvement frameworks getting started kit [Internet]. 2011 [cited 2015 Oct 7]. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/ImprovementFramework/Pages/default.aspx
  23. Institute for Healthcare Improvement. How to improve [Internet]. No date [cited 2015 Oct 7]. Available from: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
  24. Institute for Healthcare Improvement. Science of improvement: Tips for setting aims [Internet]. No date [cited 2015 Oct 7]. Available from: http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTipsforSettingAims.aspx
  25. Institute for Healthcare Improvement. Science of improvement: Establishing measures [Internet]. No date [cited 2015 Oct 7]. Available from: http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
  26. Alshaikh M, Mayet A, Adam M, Ahmed Y, Aljadhey H. Intervention to reduce the use of unsafe abbreviations in a teaching hospital. Saudi Pharmaceutical Journal [Internet]. 2013 [cited 2015 Oct 7]; 21(3):277-80. Available from http://www.sciencedirect.com/science/article/pii/S1319016412000965
  27. Thomas, AN, Boxall EM, Laha SK, Day AJ, Grundy D. An educational and audit tool to reduce prescribing errors in intensive care. Quality and Safety in Health Care. 2008; 17:360-363.
  28. Raymond CB, Sproll B, Coates J, Woloschuk D. Evaluation of a medication order writing standards policy in a regional health authority. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada [Internet]. 2013 [cited 2015 Oct 7]; 146(5):276-283. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785189
  29. Garbutt J, Milligan P, McNaughton C, Highstein G, Waterman B. Dunagan W. et al. Reducing medication prescribing errors in a teaching hospital. The Joint Commission Journal on Quality and Patient Safety. 2008; 34(9):528-536.
  30. Wachter RM, Pronovost PJ, Shekelle, PG. Strategies to improve patient safety: the evidence base matures. Annals of Internal Medicine. 2013; 158(5 part 1):350-352.
  31. Institute for Safe Medication Practices Canada. Ontario critical incident learning: Designing effective recommendations [Internet]. 2013 [cited 2015 Oct 7]; (4). Available from: http://www.ismp-canada.org/download/ocil/ISMPCONCIL2013-4_EffectiveRecommendations.pdf
  32. Institute for Safe Medication Practices. Medication error prevention ‘toolbox’. Acute Care ISMPMedication Safety Alert [Internet]. 1999 [cited 2015 Oct 7]; June 2. Available from: https://www.ismp.org/newsletters/acutecare/articles/19990602.asp
  33. Sittig DF, Singh H. Electronic health record and national patient-safety goals. New England Journal of Medicine. 2012; 367(19)1854-1860.
  34. Lewis AW, Bolton N, McNulty S. Reducing inappropriate abbreviations and insulin prescribing errors through education. Diabetic Medicine; 27(1):125-126.
  35. Burkiewicz J and Hassenplug K. Educational interventions to reduce frequency of use of restricted abbreviations in a community health center. Journal of Pharmacy Technology. 2006; 22:332-335.
  36. Abushaiqa M, Zaran F, Bach D. Education interventions to reduce the use of unsafe abbreviations. American Journal of Health-System Pharmacy. 2007; 64:1170-1173.
  37. Clarke NR, Narendran P. Insulin prescribing is unsafe: Education results in a significant but insufficient improvement. Diabetic Medicine. 2005; 22:1778-1784.
  38. Taylor S, Chu M, Haack L et al. An intervention to reduce the use of error-prone prescribing abbreviations in the emergency department. Journal of Pharmacy Practice and Research. 2007; 37(3):214-216.
  39. Ivers N, Jamtvedt G, Flottorp S et al. Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews [Internet]. 2012 [cited 2015 Oct 7]; 6. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000259.pub3/pdf/abstract
  40. Institute of Safe Medication Practices. ISMP’s guideline for standard order sets [Internet]. 2010. [cited 2015 Oct 7]. Available from: http://www.ismp.org/tools/guidelines/standardordersets.pdf
  41. Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on medication errors in a multispecialty group practice. Journal of the American Medical Informatics Association [Internet]. 2010 [cited 2015 Oct 7]; 17:78-84. Available from http://jamia.oxfordjournals.org/content/17/1/78
  42. Kaushal R, Kern L, Barron Y, et al. Electronic prescribing improves medication safety in community-based office practices. Journal of General Internal Medicine. 2010; 25(6):530-536.
  43. Cohen M. Unsafe naming, labeling and packaging of medicines: A global patient safety threat [press release]. Paris: International Medication Safety Network. 2013 [cited 2015 Oct 7] Oct 14. Available from: http://www.intmedsafe.net/imsn-advocacy/imsn-alerts/unsafe-naming-labeling-packaging-medicines-a-global-patient-safety-threat/
  44. National Patient Safety Agency National Reporting and Learning Service. Design for patient safety: Guidelines for safe on-screen display of medication information [Internet]. 2010 [cited 2015 Oct 7]. Available from: http://www.nrls.npsa.nhs.uk/resources/collections/design-for-patient-safety/?entryid45=66713
  45. Pennsylvania Patient Safety Reporting System. Abbreviations: a shortcut to medication errors. Pennsylvania Patient Safety Advisory [Internet]. 2005 [cited 2015 Oct 7]; 2(1). Available from: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2005/Mar2(1)/documents/19.pdf
  46. Myers JS, Gojraty S, Yang W, et al. A randomized-controlled trial of computerized alerts to reduce unapproved medication abbreviation use. Journal of the American Medical Informatics Association [Internet]. 2011 [cited 2015 Oct 7]; 18(1):17-23. Available from: http://jamia.oxfordjournals.org/content/18/1/17
  47. Institute for Safe Medication Practices Canada. Labelling and packaging: An aggregate analysis of medication incident reports [Internet]. 2013 [cited 2015 Oct 7]. Available from: http://www.ismp-canada.org/download/LabellingPackaging/ISMPC2013_LabellingPackaging_FullReport.pdf
  48. Glassman P. The Joint Commission’s ‘do not use’ list: Brief review. In: Making health care safer II: An updated critical analysis of the evidence for patient safety practices. Evidence Report/Technology Assessment Number 211. AHRQ Publication No. 13-E001-EF. Rockville: Agency for Healthcare Research and Quality; 2013 [cited 2015 Oct 7], p. 41-47. Available from: http://www.ncbi.nlm.nih.gov/books/NBK133373/
  49. Horon K, Hayek K, Montgomery C. Prohibited abbreviations: Seeking to educate, not enforce. The Canadian Journal of Hospital Pharmacy. 2012; 65(4):294-299.
  50. Weaver SJ, Lubomksi LH, Wilson RF, et al. Promoting a culture of safety as a patient safety strategy: Systematic review. Annals of Internal Medicine. 2013; 158(5):369-374.
  51. National Coordinating Council for Medication Error Reporting and Prevention. Reducing medication errors associated with at-risk behaviors by healthcare professionals [Internet]. 2007 [cited 2015 Oct 7] Available from: http://www.nccmerp.org/reducing-medication-errors-associated-risk-behaviors-healthcare-professionals
  52. World Health Organization. Multi-professional patient safety curriculum guide[Internet]. 2011[cited 2015 Oct 7]. Available from: http://whqlibdoc.who.int/publications/2011/9789241501958_eng.pdf?ua=1
  53. Brennan N, Mattick K. A systematic review of educational interventions to change behaviour of prescribers in hospital settings, with a particular emphasis on new prescribers. British Journal of Clinical Pharmacology. 2012; 75(2):359-372.
  54. National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to enhance accuracy of prescription writing [Internet]. 2005 [cited 2015 Oct 7]. Available from: http://www.nccmerp.org/recommendations-enhance-accuracy-prescription-writing
  55. Institute of Safe Medication Practices. Principles of designing a medication label for community and mail order pharmacy prescription packages [Internet]. 2010 [cited 2015 Oct 7]. Available from: http://www.ismp.org/tools/guidelines/labelFormats/comments/printerVersion.pdf
  56. Institute of Safe Medication Practices. ISMP list of high-alert medications in community/ambulatory healthcare [Internet]. 2011 [cited 2015 Oct 7]. Available from: http://www.ismp.org/communityRx/tools/ambulatoryhighalert.asp
  57. Institute of Safe Medication Practices. ISMP’s list of high-alert medications in acute care settings [Internet]. 2012 [cited 2015 Oct 7]. Available from: http://www.ismp.org/Tools/institutionalhighAlert.asp
  58. Institute of Safe Medication Practices Canada. Knowledge translation of insulin use interventions/safeguards. Report to Ontario Ministry of Health and Long-term Care [Internet]. 2012 [cited 2015 Oct 7]. Available from: http://www.ismp-canada.org/download/insulin/KnowledgeTranslationInsulinInterventions.pdf
  59. Cobaugh DJ, Maynard G, Cooper L, et al. Enhancing insulin use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel. American Journal of Health-System Pharmacy. 2013; 70:1404-1413.
  60. Cohen MR. Pharmacists’ role in ensuring safe and effective hospital use of insulin. American Journal of Health-System Pharmacy. 2010; 67(16 Suppl 8):517-21.
  61. Pennsylvania Patient Safety Reporting System. Medication errors with dosing of insulin: problems across the continuum. Pennsylvania Patient Safety Advisory [Internet]. 2010 [cited 2015 Oct 7]; 7(1):9-17. Available from: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Mar7(1)/documents/09.pdf
  62. Cohen M, editor. Medication errors. 2nd ed. Washington: American Pharmacists Association; 2007.
  63. Institute for Safe Medication Practices. Use of “NoAC” abbreviation. ISMP Medication Safety Alert Acute Care. 2013 Dec 12.
  64. Koczmara CV, Jelincic V, Dueck C. Dangerous abbreviations: “U” can make a difference! Dynamics. 2005; 16(3), 11-15.
  65. Baysari MT, Welch S, Richardson K, et al. Error prone abbreviations in hospitals: Is technology the answer? Journal of Pharmacy Practice and Research. 2012; 42(3):246.
  66. Shultz J, Strosher L, Nathoo SN. Avoiding potential medication errors associated with non-intuitive medication abbreviations. Canadian Journal of Hospital Pharmacy. 2011; 64(4):246-251.
  67. Pennsylvania Patient Safety Reporting System. Drug name suffix confusion is a common source of errors. Pennsylvania Patient Safety Advisory [Internet]. 2004 [cited 2015 Oct 7]; 1(4). Available from: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2004/dec1(4)/documents/17.pdf
  68. National Coordinating Council for Medication Error Reporting and Prevention. Promoting the safe use of suffixes in prescription drug names [Internet.] 2007 [cited 2015 Oct 7]. Available from: http://www.nccmerp.org/promoting-safe-use-suffixes-prescription-drug-names
  69. Institute of Safe Medication Practices. ISMP’s list of products with drug name suffixes [Internet]. 2010 [cited 2015 Oct 7]. Available from: http://www.ismp.org/Tools/drugnamesuffixes.pdf
  70. International Medication Safety Network. Position Statement. Making medicines naming, labeling and packaging safer [Internet]. 2013 [cited 2015 Oct 7]. Available from: http://www.intmedsafe.net/wp-content/uploads/2014/07/Making-Medicines-Naming-Labeling-and-Packaging-Safer-Final-A4-2013.pdf
  71. Kaushal R, Goldman DA, Keohane CA, et al. Medication errors in paediatric outpatients. Quality & Safety in Health Care [Internet]. 2010 [cited 2015 Oct 7]; 19(6):e30. Available from: http://qualitysafety.bmj.com/content/19/6/e30.full
  72. Sheppard JE, Weidner LCE, Zakai S, et al. Ambiguous abbreviations: An audit of abbreviations in paediatric note keeping. Archives of Disease in Childhood. 2007; 93:204-206.
  73. Yin HS, Wolf MS, Dreyer BP, et al. Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications. The Journal of the American Medical Association. 2010; 304(23):2595-2602.
  74. US Department of Health and Human Services. Guidance for industry: Dosage delivery devices for OTC liquid drug products [Internet]. 2011 [cited 2015 Oct 7]. Available from: http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM188992.pdf
  75. Poloway L, Greenall J. Medication safety alerts – Taking action on error-prone abbreviations. Canadian Journal of Hospital Pharmacy. 2006; 59(4):206-209.
  76. Lopatka H. Final report: Implementing a list of error prone prohibited medical abbreviations. Evaluating the intervention impact on physician prescribing behaviour in the David Thompson Health Region. Calgary: Health Quality Council of Alberta; 2008.
  77. Langlois T. Alberta Health Services. Personal communication. September 2014.
  78. Bachand R. Vancouver Island Health Authority. Director, Medication Safety and Antimicrobial Stewardship Program. Personal communication (e-mail). March 2014.
  79. Accreditation Canada. Canadian health accreditation report. Safety in Canadian Health Organizations: The 2014 Accreditation Canada Report on Required Organizational Practices [Internet]. 2014 [cited 2015 Oct 7]. Available from: https://accreditation.ca/sites/default/files/rop-report-2014-en.pdf
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  82. Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Annals of Internal Medicine. 2013; 158(5):365-368.
  83. Australian Commission on Safety and Quality in Health Care and NSW Therapeutic Advisory Group Inc. National Quality Use of Medicines Indicators for Australian Hospitals [Internet]. Sydney: Australian Commission on Safety and Quality in Health Care; 2007 [cited 2015 Oct 7]. Available from:http://www.ciap.health.nsw.gov.au/nswtag/documents/publications/indicators/manual.pdf
  84. Health Quality & Safety Commission New Zealand. Error-prone abbreviations, symbols and dose designations not to use [Internet]. Medication Alert. 2012 [cited 2015 Oct 7]. Available from: http://www.hqsc.govt.nz/assets/Medication-Safety/Alerts-PR/Abbreviations-when-prescribing-medicines-Oct-2012.pdf
  85. Davis N. Medical abbreviations: 32,000 conveniences at the expense of communication and safety. 15th ed. Philadelphia: Neil M. Davis Associates; 2011. Also available in an online format, c2014 [cited 2015 Oct 7]. Available from: http://www.medabbrev.com
  86. MacKinnon NJ, editor. Safe and effective: The eight essential elements of an optimal medication use system. Ottawa: Canadian Pharmacists Association; 2007.
  87. Mendonca JMD, Lyra DP, Rabelo JS, et al. Analysis and detection of dental prescribing errors at primary health care units in Brazil. Pharmacy World & Science. 2010; 32(1):30-35
  88. Leonhardt KK, Botticelli J. Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians. Journal of Patient Safety. 2006; 2(3):147-153.
  89. Capraro A, Stack A, Harper B et al. Detecting unapproved abbreviations in the electronic medical record. Joint Commission Journal on Quality and Patient Safety. 2012; 38(4): 178-183.
  90. Perla RJ, Provost LP, Murray SK. The run chart: a simple analytical tool for learning from variation in healthcare processes. BMJ Quality and Safety. 2011;20:46-51.