Focus on Safe Medication Practices

• Chapter 1:: Defining the Issues

  • Definitions
  • Types of Medication Incidents
  • Studies of Patient Safety
  • The Impact of Adverse Drug Events and Medication Errors
  • Summary
  • Reflective Questions

  Chapter 2:: Why Medication Incidents Occur

• Error Theory
• Studies of Contributory Factors
• Classification of Contributory Factors
• Immediate or Common Causes of Medication Incidents
• Root or System Causes of Medication Incidents
• Summary
• Reflective Questions

Chapter 3:: Prevention of Medication Incidents:: Risk Management to Improve Patient Safety

Elements of Risk Management in Pharmacy System Preventive Strategies General Preventive Strategies for Organizations Preventive Strategies for Pharmacies Personal Preventive Strategies Summary Reflective Questions

Chapter 4:: Common Causes of Medication Incidents and Preventions Strategies

Illegible Handwriting Look-Alike/Sound-Alike Medications Verbal Prescriptions Faxed Prescriptions Missing Information Abbreviations and Symbols Calculation and Decimal Point Errors Drug Device Errors Lack of Patient Education/Understanding Failed Communication with Patients Summary Reflective Questions

Chapter 5:: Underlying Root Causes and Prevention Strategies

Psychological and Human Factors Dispensing Process Manufacturer Issues Reconciliation Pharmacy Workload Environment Organizational Issues Summary Reflective Questions

Chapter 6:: Causes and Preventions Strategies in Specialty Practices

Pediatrics Compounding Nonprescription Medications Immunization Methadone Treatment Summary Reflective Questions

Chapter 7:: Technological Solutions to Promoting Safe Medication Practices

Computerized Physician Order Entry (CPOE) E-prescribing Bar Code Technology Radio Frequency Identification Automated Dispensing Other Technologies That Can Reduce Medication Error Rates Limitations of Technology in Medication Error Reduction Automation Case Study Unit-Dose Systems Point-of-Care Medication Administration Systems The Impact of Facilities Design Summary Reflective Questions

Chapter 8:: Dealing with Medication Incidents in Pharmacy

Plan of Action for Handling a Medication Incident Protocol for Handling a Medication Incident Incident Reporting Root Cause Analysis Communication of a Medication Incident/Disclosure Staff Issues During a Medication Incident Summary Reflective Questions

Chapter 9:: Instituting Safe Medication Practices in Pharmacy

Continuous Quality Improvement Failure Mode Effects Analysis Self-Assessment Other Methods for Improving Patient Safety Developing a Patient Safety Plan Barriers to Patient Medication Safety Summary Reflective Questions

Appendix A:: Organizations Involved in Patient Safety

Appendix B:: Strategies and Tools for Prevention of Specific Types of Problems

Glossary

Index