MEDICATION ERRORS This title has been archived.

Author: Michael Cohen, RPh, MS, ScD,
Affiliation: Institute for Safe Medication Practices, Huntingdon Valley, PA
Publisher: American Pharmacists Association
Publication Date: 2007
ISBN 10: 1582120927
ISBN 13: 9781582120928
Edition: 2nd

Description:

In the second, expanded edition of the acclaimed Medication Errors, Michael R. Cohen, brings together some 30 experts from medicine, nursing, risk management to provide the best, most current thinking about medication errors. Their contributions make this the most comprehensive, authoritative examination in print of the causes of medication errors and strategies to prevent them. Medication Errors provides the health care community—acute care, long-term care, ambulatory care, the pharmaceutical industry, regulatory affairs, and academia—with practical guidance to make patients who take or receive medication safer.

Table of Contents

Front Matter

  • ABOUT
  • DEDICATION
  • Notice
  • Foreword
  • Preface
  • Acknowledgments
  • Contributors

PART I PREPARING FOR ACTION

    SYSTEMS ANALYSIS AND REDESIGN: THE FOUNDATION OF MEDICAL ERROR PREVENTION

    • EXTENT OF MEDICAL INJURY
    • TRADITIONAL APPROACH TO ERROR
    • PSYCHOLOGICAL AND HUMAN-FACTORS RESEARCH
    • SYSTEMS CAUSES OF ERRORS
    • INDUSTRIAL MODELS
    • THE MEDICAL MODEL
    • MEASURING ERRORS
    • FRAMEWORK FOR SYSTEMS ANALYSIS
    • RETROSPECTIVE SYSTEMS ANALYSIS
    • PROSPECTIVE SYSTEMS ANALYSIS
    • OBSTACLES TO SYSTEMS REDESIGN
    • CONCLUSION
    • REFERENCES

    RESEARCH ON ERRORS IN DISPENSING AND MEDICATION ADMINISTRATION

    • CLINICAL SIGNIFICANCE OF MEDICATION ERRORS
    • ECONOMIC IMPACT
    • FREQUENCY OF MEDICATION ERRORS
    • TERMINOLOGY
    • TYPES OF ERRORS
    • METHODS FOR DETECTING ERRORS
    • REVIEW OF MEDICATION ERROR RESEARCH
    • DISPENSING ERRORS IN PRESCRIPTION-FILLING OPERATIONS
    • EFFECT OF WORK ENVIRONMENT AND WORKLOAD
    • APPLICATIONS OF ERROR-MONITORING TECHNIQUES
    • RECOMMENDATIONS FOR ERROR PREVENTION
    • FUTURE RESEARCH DIRECTIONS
    • CONCLUSION
    • REFERENCES

    HEALTH CARE PROVIDERS’ EXPERIENCES WITH MAKING FATAL MEDICATION ERRORS

    • BACKGROUND RESEARCH
    • CONCEPTUAL PERSPECTIVES
    • INTERVIEWS WITH CAREGIVERS
    • THE CLUB OF HURT AND PAIN
    • DISCUSSION
    • REFERENCES

PART II UNDERSTANDING THE CAUSES OF MEDICATION ERRORS

    CAUSES OF MEDICATION ERRORS

    • A SYSTEMS APPROACH
    • SYSTEM ELEMENTS IMPLICATED IN ERRORS
    • CONCLUSION
    • REFERENCES

    ROOT CAUSE ANALYSIS OF MEDICATION ERRORS

    • CONSIDER THE ENVIRONMENT
    • STEPS IN RCA
    • AGGREGATED ROOT CAUSE ANALYSIS
    • SYSTEM-LEVEL VULNERABILITIES
    • HUMAN-FACTORS ENGINEERING
    • ACTIONS AND OUTCOMES
    • UTILITY OF RCA IN THE MEDICATION-USE PROCESS
    • CONCLUSION
    • REFERENCES
    • APPENDIX

    THE ROLE OF DRUG NAMES IN MEDICATION ERRORS

    • PREVENTING ERRORS INVOLVING SIMILAR DRUG NAMES
    • LISTS OF SIMILAR NAME PAIRS
    • GENERIC NAME MIX-UPS
    • TRADEMARK SUFFIXES
    • AD HOC ABBREVIATIONS
    • BRAND-NAME EXTENSIONS
    • FOREIGN DRUG NAMES AND IMPACT OF REIMPORTATION
    • ROLE OF FDA
    • ROLE OF THE PHARMACEUTICAL INDUSTRY
    • ROLE OF PRACTITIONERS AND ORGANIZATIONS
    • CONCLUSION
    • REFERENCES

    THE ROLE OF DRUG PACKAGING AND LABELING IN MEDICATION ERRORS

    • HUMAN FACTORS AND CONFIRMATION BIAS
    • READABILITY OF LABELS AND PACKAGES
    • USES OF COLOR
    • PROBLEMS WITH USES OF COLOR
    • TWO-SIDED LABELING
    • CONTRAST
    • EXPRESSIONS OF CONCENTRATION AND STRENGTH
    • LABELING OF BLISTER STRIPS
    • COMPANY NAME, LOGO, AND CORPORATE DRESS
    • SYMBOLS
    • STANDARDIZATION OF TERMINOLOGY
    • LABEL REMINDERS AND WARNINGS
    • TYPEFACE
    • EXPRESSING PRODUCT EXPIRATION DATES
    • USE OF UNSAFE ABBREVIATIONS AND DOSE DESIGNATIONS
    • BAR CODES
    • CONTAINER DESIGN
    • PROTECTIVE OVERWRAPS
    • EXTERNAL CARTON LABELS
    • PROMOTIONAL ITEMS AND ADVERTISEMENTS
    • BRAND NAME EXTENSIONS FOR NONPRESCRIPTION DRUGS
    • DRUG SHORTAGES
    • INTERNATIONAL EFFORTS
    • PROSPECTIVE ANALYSIS TO PREVENT LABELING AND PACKAGING PROBLEMS
    • CONCLUSION
    • REFERENCES

    ERROR-PRONE ABBREVIATIONS AND DOSE EXPRESSIONS

    • NEED FOR STANDARDS
    • BREAKING HABITS
    • MISINTERPRETATIONS AND MULTIPLE MEANINGS
    • SYMBOLS
    • NUMBERS
    • DRUG NAME ABBREVIATIONS AND COINED NAMES
    • HIGH-RISK ABBREVIATION USE
    • DISCUSSION
    • REFERENCES

PART III PREVENTING MEDICATION ERRORS: A SHARED RESPONSIBILITY

    PREVENTING PRESCRIBING ERRORS

    • ELEMENTS OF THE MEDICATION ORDER OR PRESCRIPTION
    • ORDER-WRITING PRACTICES
    • METHODS OF COMMUNICATING ORDERS OR PRESCRIPTIONS
    • FORMULARY SYSTEMS
    • SAMPLE MEDICATIONS
    • RESOLVING CONFLICTS IN DRUG THERAPY
    • CONCLUSION
    • REFERENCES

    PREVENTING DISPENSING ERRORS

    • ERRORS RELATED TO THE WORK ENVIRONMENT
    • ERRORS RELATED TO INFORMATION ABOUT THE DRUG OR PATIENT
    • ERRORS RELATED TO DISPENSING METHODS
    • AUTOMATED AND MANUAL REDUNDANCIES
    • COUNSELING PATIENTS
    • CLINICAL PHARMACY ACTIVITIES
    • REFERENCES
    • APPENDIX

    PREVENTING DRUG ADMINISTRATION ERRORS

    • OBTAINING PATIENT INFORMATION
    • IDENTIFYING THE PATIENT
    • MONITORING THE PATIENT
    • COMMUNICATING PATIENT INFORMATION TO PHARMACY
    • DRUG AND DOSING INFORMATION
    • COMMUNICATING DRUG INFORMATION ACCURATELY
    • DRUG LABELING, PACKAGING, AND NOMENCLATURE
    • DRUG STORAGE AND STANDARDIZATION
    • ENVIRONMENT, WORKFLOW, AND STAFFING PATTERNS
    • STAFF COMPETENCY AND EDUCATION
    • PATIENT EDUCATION
    • QUALITY PROCESSES AND RISK MANAGEMENT
    • REFERENCES

    PREVENTING MEDICATION ERRORS RELATED TO DRUG DELIVERY DEVICES

    • INFUSION PUMPS
    • PATIENT-CONTROLLED ANALGESIA DEVICES
    • ORAL SYRINGES
    • ENTERAL FEEDINGS
    • OTHER TUBING MISCONNECTIONS
    • REFERENCES

    THE PATIENT’S ROLE IN PREVENTING MEDICATION ERRORS

    • THE BASIC QUESTIONS
    • PROVIDING INSTRUCTIONS TO PATIENTS
    • PATIENT RECORD KEEPING
    • SAFE DRUG USE BY PATIENTS: KEY POINTS
    • ADHERENCE: THE OTHER SIDE OF SAFE DRUG USE
    • SPECIFIC PATIENT POPULATIONS
    • CONCLUSION
    • REFERENCES
    • APPENDIX

PART IV PREVENTING MEDICATION ERRORS: SPECIFIC MEDICATIONS, PATIENTS, AND CONDITIONS

    HIGH-ALERT MEDICATIONS: SAFEGUARDING AGAINST ERRORS

    • A FRAMEWORK FOR IMPROVEMENT
    • SAFEGUARDING HIGH-ALERT DRUG USE
    • SPECIFIC SAFETY IMPROVEMENTS
    • REFERENCES

    USING TECHNOLOGY TO PREVENT MEDICATION ERRORS

    • GETTING STARTED
    • PHARMACY COMPUTER SYSTEMS
    • AUTOMATED DISPENSING CABINETS
    • COMPUTERIZED PRESCRIBER ORDER ENTRY
    • POINT-OF-CARE BAR CODE MEDICATION ADMINISTRATION
    • “SMART” PUMPS
    • STANDALONE DATA-MONITORING TECHNOLOGY
    • CONCLUSION
    • REFERENCES
    • APPENDIX

    PREVENTING MEDICATION ERRORS IN CANCER CHEMOTHERAPY

    • EDUCATING HEALTH CARE PROVIDERS
    • VERIFYING THE DOSE
    • ESTABLISHING DOSAGE LIMITS
    • STANDARDIZING THE PRESCRIBING VOCABULARY
    • WORKING WITH MANUFACTURERS
    • EDUCATING PATIENTS
    • IMPROVING COMMUNICATION
    • NEED FOR PHARMACIST INVOLVEMENT IN CHEMOTHERAPY
    • CONCLUSION
    • REFERENCES
    • APPENDIX

    PREVENTING MEDICATION ERRORS IN PEDIATRIC AND NEONATAL PATIENTS

    • REASONS FOR INCREASED RISK OF ERROR
    • ENSURING STAFF COMPETENCIES
    • MEDICATION SAFETY IN PEDIATRIC EMERGENCIES
    • MEDICATION SAFETY FOR PEDIATRIC PATIENTS IN THE OPERATING ROOM
    • ROLE OF AUTOMATION IN PEDIATRIC AND NEONATAL SERVICES
    • REFERENCES

    PREVENTING MEDICATION ERRORS WITH IMMUNOLOGIC DRUGS

    • DRUG LABELING, PACKAGING, AND NOMENCLATURE
    • UNCLEAR COMMUNICATION
    • LACK OF PATIENT INFORMATION
    • PROBLEMS WITH PREPARATION, DOSING, AND ADMINISTRATION
    • STANDARDIZATION, STORAGE, AND DISTRIBUTION
    • ENVIRONMENTAL FACTORS
    • ADMINISTRATION ROUTES AND TECHNIQUE
    • RISK MANAGEMENT AND QUALITY PROCESSES
    • IMPLICATIONS FOR HEALTH CARE PRACTITIONERS
    • REFERENCES

PART V REDUCING RISKS AND CREATING A JUST CULTURE OF SAFETY

    MEDICATION ERROR REPORTING SYSTEMS

    • PURPOSE OF REPORTING SYSTEMS
    • RESPONSIBILITY FOR REPORTING
    • REPORTABLE EVENTS, CONDITIONS, AND PRIORITIES
    • REPORTING MECHANISMS
    • WHEN TO REPORT
    • WHAT INFORMATION TO REPORT
    • CATEGORIZING REPORTS
    • MANDATORY REPORTING PROGRAMS
    • VOLUNTARY REPORTING PROGRAMS
    • DISCLOSURE OF ERROR REPORTS
    • PRACTITIONERS’ PERSPECTIVES ON REPORTING
    • CONCLUSION
    • REFERENCES
    • APPENDIX A IMPACT OF UNITED STATES PHARMACOPEIA (USP)–INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) MEDICATION ERRORS REPORTING PROGRAM (MERP)
    • APPENDIX B EXAMPLES OF FINDINGS FROM U.S. PHARMACOPEIA MEDMARX REPORTING SYSTEM, 1999–2004

    DISCLOSING MEDICATION ERRORS TO PATIENTS AND FAMILIES

    • WHAT CONSTITUTES SUCCESSFUL DISCLOSURE?
    • PATIENTS’ PERSPECTIVE
    • HEALTH CARE PROVIDERS’ PERSPECTIVE
    • EXPERIENCE WITH A FULL DISCLOSURE POLICY
    • LEGAL CONCERNS
    • PERSONAL BARRIERS
    • WHAT TO DISCLOSE?
    • WHO SHOULD DISCLOSE THE ERROR?
    • MODELS OF DISCLOSURE
    • AVAILABLE TOOLS
    • STAFF EDUCATION AND SUPPORT
    • CONCLUSION
    • REFERENCES

    HEALTH CARE FAILURE MODE AND EFFECTS ANALYSIS

    • I INTRODUCTION TO FAILURE MODE AND EFFECTS ANALYSIS
    • II AN APPLICATION OF FAILURE MODE AND EFFECTS ANALYSIS
    • III VETERANS HEALTH ADMINISTRATION APPROACH TO FAILURE MODE AND EFFECTS ANALYSIS

    THE CLINICAL BIOETHICS OF SAFE MEDICATION PRACTICES

    • CLINICAL BIOETHICS
    • MORAL THEORIES
    • PRINCIPLES
    • CODES OF ETHICS
    • SAFE MEDICATION PRACTICES AND CURRENT VIEWS OF HEALTH CARE
    • CONCLUSION
    • REFERENCES

    MANAGING MEDICATION RISKS THROUGH A CULTURE OF SAFETY

    • DEFINING A CULTURE OF SAFETY
    • STRATEGIC EMPHASIS ON SAFETY
    • MINDFULNESS AND RESILIENCE
    • JUST CULTURE
    • TEAMWORK AND LOCALIZED DECISION-MAKING
    • ERROR-DEFYING SYSTEMS AND REDUNDANCY
    • PROACTIVE FOCUS AND COMMUNITY INVOLVEMENT
    • LEARNING CULTURE
    • SAFETY MEASUREMENT
    • CONCLUSION
    • REFERENCES

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