MEDICATION ERRORS This title has been archived.
Author: Michael Cohen, RPh, MS, ScD,
Publisher: American Pharmacists Association
Publication Date: 2007
Publisher: American Pharmacists Association
Publication Date: 2007
ISBN 10: 1582120927
ISBN 13: 9781582120928
Edition: 2nd
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
PART I PREPARING FOR ACTION
- 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
- 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
SYSTEMS ANALYSIS AND REDESIGN: THE FOUNDATION OF MEDICAL ERROR PREVENTION
RESEARCH ON ERRORS IN DISPENSING AND MEDICATION ADMINISTRATION
HEALTH CARE PROVIDERS’ EXPERIENCES WITH MAKING FATAL MEDICATION ERRORS
PART II UNDERSTANDING THE CAUSES OF 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
- 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
CAUSES OF MEDICATION ERRORS
ROOT CAUSE ANALYSIS OF MEDICATION ERRORS
THE ROLE OF DRUG NAMES IN MEDICATION ERRORS
THE ROLE OF DRUG PACKAGING AND LABELING IN MEDICATION ERRORS
ERROR-PRONE ABBREVIATIONS AND DOSE EXPRESSIONS
PART III PREVENTING MEDICATION ERRORS: A SHARED RESPONSIBILITY
- 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 PRESCRIBING ERRORS
PREVENTING DISPENSING ERRORS
PREVENTING DRUG ADMINISTRATION ERRORS
PREVENTING MEDICATION ERRORS RELATED TO DRUG DELIVERY DEVICES
THE PATIENT’S ROLE IN PREVENTING MEDICATION ERRORS
PART IV PREVENTING MEDICATION ERRORS: SPECIFIC MEDICATIONS, PATIENTS, AND CONDITIONS
- 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
HIGH-ALERT MEDICATIONS: SAFEGUARDING AGAINST ERRORS
USING TECHNOLOGY TO PREVENT MEDICATION ERRORS
PREVENTING MEDICATION ERRORS IN CANCER CHEMOTHERAPY
PREVENTING MEDICATION ERRORS IN PEDIATRIC AND NEONATAL PATIENTS
PREVENTING MEDICATION ERRORS WITH IMMUNOLOGIC DRUGS
PART V REDUCING RISKS AND CREATING A JUST CULTURE OF SAFETY
- 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
- 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
