Index

A

Accountability

performance measurement for, 330

state reporting systems for, 92

Accreditation

curricula recommendations, 344

recommendations for, 22, 329, 335

See also Joint Commission on Accreditation of Healthcare Organizations

Acetaminophen, 31, 83, 115

Acute care

patient monitoring, 8485

technologies for improving, 14

See also Emergency departments

Acute coronary syndromes, 125, 126, 373, 375

ADEs. See Adverse drug events

Adherence. See Nonadherence

Administration of medications

bar coding technology in, 81

causes of errors in, 8183

error detection by observation, 243244

error incidence, 4, 28, 110112, 114115, 369371, 376378, 395396

error prevention in ambulatory care, 429

methods, 80

overrides of automated warnings, 252

patient self-administration, 8384

in pediatric care, 114115, 395396

prevention of errors in, 8081, 83, 250251

procedure, 7980

research needs, 21

responsibility, 79

Adverse drug events (ADEs)

costs, 130133, 202

definition, 3, 45, 36, 37, 38, 311312

detection methods, 237239, 241245

incidence. See Incidence of medication errors and ADEs

monitoring for, 238

mortality, 28

patient right to know, 7

as percentage of adverse events, 28, 67

potential, 37, 109110

preventability, 6, 122, 317

preventable. See Preventable adverse drug events

reporting. See Surveillance and reporting

strategies for preventing, 6, 317

See also Medication errors

Adverse drug reaction, 38

Agency for Healthcare Research and Quality, 240, 245, 247, 409

Center for Quality Improvement and Patient Safety, 25



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Preventing Medication Errors Index A Accountability performance measurement for, 330 state reporting systems for, 92 Accreditation curricula recommendations, 344 recommendations for, 22, 329, 335 See also Joint Commission on Accreditation of Healthcare Organizations Acetaminophen, 31, 83, 115 Acute care patient monitoring, 84–85 technologies for improving, 14 See also Emergency departments Acute coronary syndromes, 125, 126, 373, 375 ADEs. See Adverse drug events Adherence. See Nonadherence Administration of medications bar coding technology in, 81 causes of errors in, 81–83 error detection by observation, 243–244 error incidence, 4, 28, 110–112, 114–115, 369–371, 376–378, 395–396 error prevention in ambulatory care, 429 methods, 80 overrides of automated warnings, 252 patient self-administration, 83–84 in pediatric care, 114–115, 395–396 prevention of errors in, 80–81, 83, 250–251 procedure, 79–80 research needs, 21 responsibility, 79 Adverse drug events (ADEs) costs, 130–133, 202 definition, 3, 4–5, 36, 37, 38, 311–312 detection methods, 237–239, 241–245 incidence. See Incidence of medication errors and ADEs monitoring for, 238 mortality, 28 patient right to know, 7 as percentage of adverse events, 28, 67 potential, 37, 109–110 preventability, 6, 122, 317 preventable. See Preventable adverse drug events reporting. See Surveillance and reporting strategies for preventing, 6, 317 See also Medication errors Adverse drug reaction, 38 Agency for Healthcare Research and Quality, 240, 245, 247, 409 Center for Quality Improvement and Patient Safety, 25

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Preventing Medication Errors data standardization role, 324 recommendations for, 12, 19, 20, 21, 192, 274, 275, 288, 310–311 Alerts and alert systems current technology, 287 false alerts and overrides, 20, 251–252, 293–294 intelligent prompting, 295–297 scope of, 287 severity ranking, 293, 294 standardization, 288, 293–295 See also Computerized drug event monitors; Computerized provider order entry Allergic reactions clinical decision support to prevent, 246 prescribing errors, 71 preventable ADEs in hospitals, 119 Ambulatory care costs of medication errors in, 5–6, 131, 132 electronic prescribing in, 14, 253 incidence of medication errors, 108, 112–114, 124, 314, 384–392, 396–397 information resources in, 206 medical record keeping in, 387–388 medication administration in, 429 medication error detection in, 244 medication therapy management in, 429–430 opportunities for patient consultation, 173–174 overutilization of medications in, 128 patient monitoring in, 323, 387 pediatric, 396–397 preventable ADEs in, 5, 124 prevention research, 319–320 research needs, 21, 314, 323 strategies for reducing errors in, 428–430 underutilization of medications in, 127–128 American Academy of Pediatrics, 29, 434 American Hospital Association, 160 American Medical Association, 410 American Medical Informatics Association, 343–344 American Nurses Association, 410 American Society of Health-System Pharmacists, 29, 429 American Society of Hospital Pharmacists, 410 Anesthesia Patient Safety Foundation, 296 Anesthesiology, 296–297, 301 Anti-anxiety drugs, 421–422 Antibiotic medications, 71, 84, 125, 126, 128, 373, 375 Anticoagulant therapy, 88–89, 125, 249, 270, 313–314, 382 Aspirin, 31, 270 Associated in Process Improvement, 157 Atrial fibrillation, 125, 127, 382 Automated dispensing systems effectiveness, 251, 418 implementation, 334 linkages among automated and computerized systems, 252, 287 overrides of warnings, 252 purpose, 30, 77–78 B Bacterial infection prophylaxis, 125, 126. See also Antibiotic medications Bar coding, 413 alert systems, 287, 293–294 error prevention efficacy, 6, 413 Food and Drug Administration rules, 297–298 future prospects, 298–299 linkages among automated and computerized systems, 252, 287 in nursing home medication use, 252–253 purpose, 14, 30, 81, 250–251 regulatory requirements, 280 research needs, 318, 319 standardization, 288, 291, 297–299 use interface, 300–301 Best Pharmaceuticals Act for Children, 268 Biologic Licensing Application, 59 Biologic products, 35 Blood and blood products, 35 Brand name drugs, 277, 278 Bridges to Excellence, 331 Bronchitis, 128 C Cancer treatment, 164 Caregivers error risk, 116, 186 incidence of pediatric medication errors, 314–315

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Preventing Medication Errors right to refuse treatment for dependents, 191 training and support for, 186 Case management, pharmaceutical, 432–433 Causes of medication errors and adverse events areas of evaluation for improving care, 33 in care transitions, 255 communication-related, 17–18, 182–183, 234, 274, 275 in computerized order entry, 74 in drug administration process, 81–83 overutilization, 125, 128–129, 274–275, 384 in pharmaceutical industry, 266–267 in pharmacy practice, 75, 76, 77, 78–79 in prescribing process, 71–74 research needs, 2, 317 risk/benefit information, 17 scope of, 37, 43, 51, 70 systemic context, 45, 184–187 transcription of prescription, 75–76, 378, 394 underutilization, 125, 126–128, 234–235, 382–384 user interface-related, 299–301 See also Dosage errors; Nonadherence Center for Health and Health Care in Schools, 434 Centers for Disease Control and Prevention adverse event reporting system, 93–94 National Center for Health Marketing, 206–207 Centers for Medicare and Medicaid Services comparative performance reports, 331 drug formularies, 66 electronic prescribing rules, 336 information dissemination role, 207 recommendations for, 12, 21, 22, 192–193, 310–311, 312, 329, 333–334 role of, 33 Certification Commission on Health Information Technology, 254–255 Chart review, 241–242 Chemical name, 275 Chemotherapy error incidence, 113 Chronic Care Model, 157–158 Chronic coronary disease, 125 Claims data, 341 Clear Rx™, 198 Clinical decision-support systems, 26, 30, 85, 122 current state, 232 effectiveness, 6, 414–417 for electronic prescribing, 247–248 future prospects, 232 implementation, 253–255 intelligent prompting, 295–297 overrides of warnings, 251–252, 293 rationale, 232 recommendations for, 16, 26, 228 standardization, 335 user interface, 300 See also Alerts and alert systems Clinical trials considerations in prescribing, 71 disclosure of results, 57–58, 271–274 informed consent rules, 159 new drug development process, 55–56 registration site, 271, 272 regulatory oversight, 63 shortcomings of current health system, 17, 56–57, 267–271 Clinical unit, 222–228 ClinicalTrials.gov, 271–272 Cochrane Collaboration, 13 Cognitive processing drug labeling and, 19, 274 medication information leaflet design considerations, 195–196, 274 patient with impairment, 185 research needs, 318 technology interface design, 20, 288, 299–302 Colds, 128 Comorbodity adverse event risk, 86 research needs, 17, 269 Complementary and alternative medications consumer health attitudes and beliefs, 189–190 definition, 35 drug interactions, 116 error prevention strategies, 435–438 information access for consumers and providers, 182 medication error rate, 108, 116, 316 patient self-prescribing, 74–75 research needs, 21, 316 utilization, 31, 32, 189

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Preventing Medication Errors Compliance. See Nonadherence Computerized drug event monitors, 30, 85–86, 242–243, 251 Computerized point-of-care reference information, 13, 229–232 Computerized prescribing. See Electronic prescribing Computerized provider order entry, 29, 232 in care transitions, 235–236 causes of error in, 300 continuous quality improvement, 255 costs and benefits, 253 effectiveness, 6, 250, 414–417 error risk in, 74, 372–373, 417 implementation, 222, 253–255, 319, 334 implementation trends, 334–335 linkages among automated and computerized systems, 85, 252, 287 in nursing homes, 252 potential for preventing ADEs, 122, 124 in psychiatric care, 321 rationale, 14, 76 research needs, 318, 319 user interface, 300 Congestive heart failure, 125, 127, 382 Congress, recommendations for, 21, 311 Consumer role in preventing medication errors consumer empowerment to enhance, 154, 158–162, 163 educational interventions to enhance, 29 health literacy and, 182–183 identifying information resources, 166 medication list maintenance, 2, 8, 164–165, 234 medication safety practices, 165–166 multidisciplinary team approach to care, 248 recommendations for enhancing, 11, 162–163 research needs, 21, 312 treatment planning, 70, 163–164 use and understanding of drug labels, 75 See also Provider–patient partnership to prevent medication errors Continuing medical education for information technology, 343–344 interoperable data for, 236 patient safety courses and resources, 343 for pharmacists, 337, 338 Continuity of Care Record, 322 Coronary artery disease, 128 Cost of care computerized order entry, 253 considerations in treatment planning, 70 containment efforts, 32 data sources, 132–133 medication spending, 202 medication therapy management, 333 observation of medication administration, 244 as obstacle to care, 10, 186–187 patterns and trends, 32 prescription drug sales, 32 risk-benefit analysis of medication use, 267–268 Costs free drug sample distribution, 284 of medication error prevention strategies, 317–318 of national telephone helpline, 202 of reporting systems, 324 See also Cost of care; Cost(s) of medication errors Cost(s) of medication errors, 28 adverse drug events, 130–133 data sources, 2, 129–130 preventable adverse drug events, 5–6 research needs, 2, 5, 6, 21, 133, 316–317 COX-2 inhibitors, 32, 268, 272 Crossing the Quality Chasm: A New Health System for the 21st Century, 6, 26, 143–144 Cultural factors barriers to provider–patient partnership, 187–191 culture of safety, 15–16, 187, 222, 255, 318 language conflict, 183 obstacles to prevention of medication errors, 10 patient-centered, integrated medication-use system, 143–145 recent efforts to promote safe care, 30–31 D DailyMed program, 12, 192, 200 Decision-support systems. See Clinical decision-support systems

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Preventing Medication Errors Depression treatment, 125, 127, 382, 422 Diabetes patient self-monitoring, 88 Dietary Supplement Health and Education Act. See Complementary and alternative medications Dietary supplements. See Complementary and alternative medications Discharge consultation, 175–176, 235 Distractions as source of medication error in drug administration, 82–83 in pharmacy, 79, 431–432 Diuretic drugs, 313–314 Dosage errors clinical knowledge base, 269–270 electronic prescribing to prevent, 246 over-the-counter drugs, 116 pediatric, 320 in pediatric care, 392–393, 394 preventable ADEs, 119, 123, 124 preventing in drug administration process, 80 in self-administration of drugs, 83–84 standardization to prevent, 320 types of errors, 71–72, 77, 82 Drug, defined, 35 Drug interactions clinical decision support to prevent, 246, 247 complementary and alternative medications, 116 examples, 88 food–drug interactions, 88 over-the-counter medications, 87, 116 patient self-monitoring for, 87 pharmacy practice to prevent, 76–77 preventable ADEs in hospitals, 119 risk, 71, 72, 88, 386–387 Drug names and abbreviations brand names, 277, 278 chemical names, 275 current practice, 275–277, 280 generic drugs, 275–277, 278 official title, 277 as source of prescribing error, 71–72, 82, 275 standardization, 18, 19, 44 Drug resistance, 71, 128 Drug system barriers to improvement, 179–180 current shortcomings, 53–54, 67–69, 90 manufacturing controls, 63 medication-use system, 66–70, 89, 90 number of pharmaceutical agents, 51 opportunities for intervention, 53, 67 principles for safe practice in, 50–51, 53 stages of drug development and delivery, 51 stakeholders, 50, 67 standards, 53 structure and operations, 51–53 systemic context of errors, 45, 53–54, 184–187 See also Administration of medications; Industry, pharmaceutical; Marketing and distribution of drugs; Pharmacy practice; Prescribing practice; Research and development, new drug E Education and training of medical personnel intern work schedules, 31, 419 in nursing homes, 423–425 prescription writing aids, 428–429 profiling and feedback, 425–426 recommendations, 344 safety courses and resources, 343 shortcomings of current system, 342–343 for use of information technology, 343–344, 427 See also Continuing medical education Educational interventions with caregivers, 186 communication skills for, 172–173, 182, 183 consumer health literacy, 182–183 core information, 172 at discharge, 175–176, 235 effectiveness, 6, 419 to enhance patient self-care, 163–164, 427, 433–434 obstacles to prevention of medication errors, 10 opportunities for consultation, 173–176 provider actions to improve medication safety, 8, 10, 171–172 provider training for, 171 recent efforts, 29 recommendations, 11, 12–13, 162, 192–193 self-management support, 158

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Preventing Medication Errors shortcomings of current system, 11–12, 179, 181–183 See also Information resources Electronic ADE detection, 242–243 Electronic health records certification, 254–255 data standards, 289 error risk, 372–373 implementation trends, 334–335, 2044 purpose, 203–204, 222, 253 standardization, 336 Electronic prescribing, 30 decision support rules, 247–248 implementation challenges, 13–14 linkages among automated and computerized systems, 252, 287 in nursing homes, 14, 252 in outpatient care, 253 oversight and implementation, 33 potential for error, 248 rationale, 13, 30, 246, 247 recommendations, 16, 228–229, 246 regulatory restrictions, 247 standardization, 335 state regulation, 336 Emergency departments cost of admissions related to prior ADEs, 130–131 medication error rates, 114–115, 397 overutilization of antibiotics in, 128 pediatric, 114–115, 397 Errors of omission, 5, 26, 28, 36, 69, 108 F Failure modes and effects analysis, 278 Fatigue, provider, 31, 419 Federal government adverse event reporting and surveillance system, 92–94 information technology role, 334 patient rights guarantees, 159–160 recommendations for, 11–13 role in preventing medication errors, 2 See also Regulation and oversight; specific agency or department Fever treatment, 116 Food and Drug Administration adverse event reporting system, 59, 92 bar coding rules, 297–298 clinical trials oversight, 159 drug labeling and packaging oversight, 19, 60–62, 193–194, 195, 196, 274–275, 279–280 drug manufacturing and distribution oversight, 63 drug name selection process, 278, 280 drug safety activities, 32–33, 51–53 error reporting systems, 89 information dissemination role, 29, 207, 312 in new drug development, 51, 55, 56, 58–60 recommendations for, 12, 19, 21, 192–193, 274–275, 310–311 Formularies characteristics of current system, 66 cost of drugs and, 187 definition, 66, 129 effects on safety, 129 effects on utilization, 129 Free drug samples, 18, 19, 65–66, 179, 275, 285–287, 387 G Generic drugs free samples, 285–287 naming conventions, 275–277, 278 Geriatric medicine adherence, physical impairment and, 184–185 clinical knowledge base, 268–269 cost of care, 187 drug information access and utilization, 181 health system trends, 32 medication regulation in nursing homes, 419–423 multidisciplinary team approach to care, 250 patient monitoring in, 86 psychotropic medications, 398–399, 419–423 risk of medication error, 17, 57, 86, 313–314, 398–399 See also Nursing homes H Hand-offs. See Transition between care settings

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Preventing Medication Errors Health care providers access to information, 181, 231–232 actions to improve medication safety, 8–10 attitudinal barriers to provider–patient partnership, 187–189 disclosure of errors to patients, 160–162, 177–179 drug industry marketing to, 65 effective clinical units, 222–228 handwriting, 74 information needs, 229–231 integration of complementary and alternative medications, 189–190 interpersonal skills, 171–173, 178 medication reconciliation, 14–15, 168–169 multidisciplinary teams, 248–250 opportunities for patient consultation, 173–176 patient education role, 171–173 performance measurement, 330–331 public opinion, 151–152, 153 recommendations for, 22, 248, 329 reporting behaviors, 152 scope of, 38 workforce development, 342–344 See also Education and training of medical personnel; Nursing; Pharmacy practice; Prescribing practice; Provider–patient partnership to prevent medication errors; Psychiatric care Health maintenance organization drug formularies, 66 Health Plan Employer Data and Information Set, 341 Hearing impairment, 185 Heart failure, 125 Hemodialysis, 113 Heparin, 270 Home care, 85, 389–390, 433. See also Ambulatory care; Transition between care settings Hormone replacement therapy, 267–268 Hospital Incident Reporting Ontology, 340 Hospitals computerized order entry in, 253–254 costs of ADEs in, 130–132 drug repackaging, 77 incidence of medication errors and ADEs, 1–2, 4, 5, 108–111, 118–122, 125, 313, 323, 367–376 opportunities for patient consultation, 174–176 performance assessment, 341 psychiatric, 399 research needs, 318–319 strategies for preventing medication errors and ADEs, 6, 318–319, 409–419 underutilization of medications in, 125, 126–127 Human factors design drug labeling, 19, 274 medication information leaflets, 195–196, 274 significance of, 50 technology interface, 20, 288, 299–302 Hypertension management, 127, 268 I Ibuprofen, 31 Incidence of medication errors and ADEs adherence-related errors, 86, 114, 179, 390–391 in ambulatory care, 108, 112–114, 124, 314, 384–392, 396–397 areas of evaluation for improving care, 33 in chronic illness, 86 in complementary and alternative medication use, 108, 116, 316 current estimates, 1–2, 28, 116–118 data sources, 105–108 definition of medication error and, 311 detection methods, 4 in drug administration, 4, 28, 110–112, 114–115, 369–371, 376–378, 395–396 in emergency care, 114–115, 397 errors of omission, 28, 108, 373–376 in geriatric medicine, 86, 398–399 in home care pharmacy, 389–390 in hospitals, 1–2, 4, 5, 108–111, 118–122, 125, 313, 323, 367–376 in mail-order pharmacy, 388–389 measurement methodologies, 109 in medication-use process, 109

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Preventing Medication Errors in nursing homes, 108, 111–112, 122–123, 313–314, 376–384 in over-the-counter drug use, 108, 116, 315 overutilization errors, 125, 128–129, 384 patient monitoring errors, 86, 371, 373, 378 in pediatric care, 4, 108, 114–115, 314–315, 393–398 in pharmacy practice, 28, 113–114, 367, 369, 376, 388–389, 394–395 in prescribing, 71, 109–110, 112–113, 114–115, 314, 367–369, 373–376, 385–387, 393–394 preventable adverse drug events, 5, 118–125, 109–110 in primary care, 86 in psychiatric care settings, 108, 115–116, 315, 398–400 research needs, 2, 3, 21, 118, 313–316, 400 in school health care, 112, 391 in self care, 114, 390–391 underutilization errors, 125, 126–128, 382–384 in use of over-the-counter drugs, 108, 116, 315 variation across facilities, 4, 117 Industry, pharmaceutical, 38 communication of drug information, 17–18, 183, 266–267 drug formularies, 66 free sample distribution, 18, 19, 65–66, 179, 275, 284–286, 387 manufacturing oversight, 63 potential sources of medication error in, 51, 266 product recalls, 51 recommendations for, 18–19, 20, 274–275, 287–288 role in improving medication safety, 150, 266–267 stages of drug development and distribution, 50, 51 See also Marketing and distribution of drugs; Research and development, new drug Informatics, 50 Information resources clinical data, 267–271 consumer access, 205 consumer behavior, 75 consumer demand, 165–166 current publishing system, 271–272 current technologies, 286–287 data standards, 20, 287, 288 design considerations, 195–196 drug labeling and packaging, 17–19, 183 drug risk/benefit information, 17 goals, 205 government role, 334 integration of technologies, 287 international comparison studies, 323 Internet, 11–12, 198–200 interoperable medication data, 233–236 medication information leaflets, 11–12, 183, 192, 193–196 for medication reconciliation, 14–15, 168–169 minimum functionality standards for technology, 22, 329, 334–336 in new drug development process, 54 patient safety educational materials for providers, 343 for patient self-prescribing, 74–75 for pharmacists, 76, 79, 234 pharmacy database, 76, 287 point-of-care reference information, 13, 229–232 for preventing drug administration errors, 83 proposal for national registry, 272–274 provider access systems, 231–232 provider needs, 229–231 publication bias, 272 recommendations for improving, 12–13, 16, 20, 192–193, 228–229, 274–275, 287–288 research to enhance consumer use and comprehension, 312 reward for investment in, 331 shortcomings of current system, 11–12, 17–18, 181–183, 267, 271–272 standardization of health information technology, 19–20, 31, 289–293 structure and scope of national medication safety system, 205–207 technology interface design, 299–302 technology training for providers, 343–344, 427 telephone helpline, 12, 192, 200–203

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Preventing Medication Errors See also Alerts and alert systems; Educational interventions; Surveillance and reporting Informed consent, 159 Institute for Healthcare Improvement, 25–26, 157, 168–169 Institute for Safe Medication Practice, 29, 89, 91, 240, 245, 341, 410 Insurance barriers to provider–patient partnership, 184 cost of care as cause of nonadherence, 186–187 drug formularies, 66, 129, 187 Intensive care units incidence of drug administration errors, 371 medication error rates in, 110 patient monitoring in, 85 International comparison, 323 Internet clinical trial data, 271, 272 consumer health behaviors, 198–199 National Library of Medicine programs, 199–200 online pharmacies, 64, 199 quality of health information on, 11–12, 199 recommendations for, 12, 192 Intravenous medication administration errors, 110, 370, 371 causes of error in, 299–300 error prevention technologies, 251 See also Smart intravenous pumps J Joint Commission on Accreditation of Healthcare Organizations, 25–26 data standardization activities, 324, 340 National Patient Safety Goals, 31, 222, 225–226, 337 patient rights oversight, 159, 160 reconciliation standards, 169 Sentinel Event Policy, 29–30, 91, 410 K Katrinahealth.org, 233–234 L Labeling and packaging black box warnings, 61 consumer use and understanding, 75 container labels, 196–198 drug interaction data, 87 drug samples, 387 over-the-counter medications, 61, 438 recommendations for, 18–19, 274–275 regulatory oversight, 60–62, 193–194, 195, 196, 278–279 shortcomings of current system, 17–18, 194, 196–198, 275, 276–277, 278–280 as source of medication error, 45, 77, 79, 267, 275 strategies for improving, 198, 280, 281–282 See also Unit-of-use packaging Leapfrog Group, 297, 331, 335 Legal environment barriers to reporting, 339 Internet pharmacies, 64 patient rights, 7 right to refuse treatment, 191 state-mandated adverse event reporting, 89, 91–92 Lehman, Betsy, 27 Libraries, 206 Lidocaine hydrochloride, 279 Long-term care cost of medication errors in, 5, 132 patient monitoring in, 85 preventable ADEs in, 5, 112, 125 See also Nursing homes M Mail order pharmacies error incidence, 388–389 legal status, 64 operations, 64 research needs, 314 Managed care organization drug formularies, 129 Marketing and distribution of drugs distribution system, 63–64 free drug samples, 18–19, 19, 65–66, 179, 275, 284–286

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Preventing Medication Errors industry spending on promotion, 64, 65 marketing effects, 65 in overall drug system, 51 promotional techniques, 64–65 regulatory review, 62, 63 shortcomings of current system, 66 Medical rounds, 6, 413, 417 Medicare adverse event risk, 86 claims data, 341 electronic prescribing rules, 336 medication therapy management in, 333–334 outpatient preventable adverse drug events, 5 prescription drug benefit, 32, 33 provider performance assessment, 341 See also Centers for Medicare and Medicaid Services Medicare Modernization Act, 335 Medicare Prescription Drug Improvement and Modernization Act, 176 Medication administration record, 81 Medication errors case examples, 27, 43–49, 152–153 cause for concern, 1, 26–28 costs. See Cost(s) of medication errors definition, 3, 36–37, 311–312 detection methods, 237–239, 241–245 disclosure, 160–162, 177–179 frequency. See Incidence of medication errors and ADEs mortality, 25 preventability, 2 public perception, 151–152 reporting. See Surveillance and reporting research needs, 2, 150, 310 settings, 3–4, 28, 35, 67–69 types of products involved in, 35, 67–69 See also Adverse drug events Medication Modernization Act, 33 Medication Safety Alert newsletter, 240 Medication therapy management, 22, 329, 333–334, 426, 429–430 Medline Plus, 12, 192, 199–200 MedMARx Program, 89, 240, 245 MedWatch program, 61, 89, 92, 340–341 Microsoft, 301 Monitoring, patient in ambulatory care, 323, 387 chart review, 241–242 computerized drug event monitors, 30, 85–86, 242–243, 251 errors in nursing homes, 112, 378 errors in pediatric care, 396 goals, 2, 15, 84, 86–87 intelligent prompting systems, 295–297 methods and technologies, 84, 85 observation of medication administration, 243–244 patient self-monitoring, 87–89 pharmacist role, 85–86 preventable ADEs related to, 371, 373 provider knowledge for, 87 recommendations for, 16, 228 research needs, 322–323 responsibility, 84 scope, 84–85 See also Alerts and alert systems; Computerized drug event monitors; Surveillance and reporting Monoamine oxidase inhibitors, 88 Mortality, 25, 28 Multidisciplinary team approach to care, 248–250 Myocardial infarction, 125, 126, 127, 382 N National Academy for State Health Policy, 91, 92 National Center for Health Marketing, 206–207 National Committee on Vital and Health Statistics, 289, 335 National Consumers League, 29 National Coordinating Council for Medication Error Reduction and Prevention, 29, 410 National Council for Prescription Drug Programs, 233 National Library of Medicine drug nomenclature standardization, 289 information dissemination role, 207 on-line information resources, 199–200 recommendations for, 12, 20, 21, 192–193, 274, 287, 312 National Nosocomial Infection Survey, 91 National Quality Forum, 29, 30, 222, 227, 331 National Voluntary Consensus Standards for Ambulatory Care, 332

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Preventing Medication Errors Near miss, 311–312 New Drug Application, 59, 270–271 Nonadherence causes of, 179, 184 cognitive impairment and, 185 consumer health attitudes and beliefs and, 189 cost of care and, 186–187 costs of, 6 definition, 179 drug side effects as cause of, 186 incidence, 86, 114, 179, 390–391 interventions to prevent, 434 physical impairment as cause of, 184–185 provider–consumer communication and, 182 Nursing adequate staffing, 30 case example of medication error, 43–45 drug administration procedure, 79–80 drug effect monitoring responsibility, 84 education programs for nurses, 342 educational interventions in nursing homes, 423, 424–425 home health care, 390 interpersonal skill training, 172 observation of medication administration, 243–244 strategies for improving medication safety, 80, 222, 225 workload issues, 82 Nursing homes automated and computerized medication-use technologies for, 14, 252–253 costs of medication errors in, 131 drug administration in, 376–378 incidence of medication errors and ADEs, 108, 111–112, 122–123, 313–314, 376–384 overutilization errors, 384 research needs, 319 strategies for preventing medication errors and ADEs, 6, 319, 419–427 underutilization of medications in, 127, 382–384 workforce education, 423–425 See also Long-term care O Official title of medication, 277 Off-label use, 71, 268 Omnibus Budget Reconciliation Act, 419–420, 421–422, 423 Organizational psychology, 50 Orphan drugs, 77 Osteoporosis, 125, 127, 382 Outpatient care. See Ambulatory care Overdose case example, 43–45 in self-administration of drugs, 83 See also Dosage errors Over-the-counter medications consumer role in improving safety, 8 definition, 35 disease– and drug–drug interactions, 116, 315–316 dosing errors, 83 incidence of medication errors, 108, 116, 315 label warnings, 61, 438 patient self-prescribing, 74–75 regulatory review, 60 research needs, 21, 315–316 scope of, 51 self-monitoring when using, 87–88 strategies for error prevention, 435–438 utilization, 31 P Pain management, 125, 127, 382–384 Patient-centered care attitudinal barriers to, 188–189 characteristics of organizational culture based on, 188 conceptual model, 157–158 consumer empowerment in, 158–162, 163–164 consumer expectations, 153 essential elements, 153–155, 156 goals for, 143–150 provider responsibilities, 166 quality of communications in, 155, 172–173 rationale, 155–157 self-management support in, 157–158 See also Provider–patient partnership to prevent medication errors

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Preventing Medication Errors Patient rights clinical significance, 7, 158 current standards, 7–8, 159–160 to disclosure of adverse events, 7, 160–162, 177–179 informed consent, 159 pharmacy consultation, 176 provider responsibility, 8–10 recommendations, 11, 162 right to refuse treatment, 191 in treatment planning, 159 Patient Safety: Achieving a New Standard for Care, 26 Patient Safety and Quality Improvement Act, 91, 244–245, 339, 340 Patient Safety Event Taxonomy, 324, 340 Pediatric medicine caregiver error in fever treatment, 116 clinical knowledge base, 268 emergency care, 397 immunizations, 396–397 incidence of medication error, 4, 108, 114–115, 314–315, 393–398 medication error risk, 17 patient monitoring, 396 pharmacy practice, 77, 114 prescribing practice, 393–394 research needs, 320–321 strategies for medication error prevention, 320–321, 435 surrogate decision-making, 191 People’s Medical Society, 29 Performance measurement, 341 pathways to quality improvement, 330–331 pay-for-performance systems, 331–333 Personal health record consumer self-management and, 312–313 current state, 203–204 essential components, 204–205 interoperable medication data, 233–236 minimum data set, 12, 193, 312 rationale, 203–204 recommendations for, 12, 16, 193, 228 reconciliation in care transitions, 14–15, 168–169 types of, 204 vendor responsibilities, 12 See also Electronic health records Pharmacy benefits manager, 64 Pharmacy practice alert systems, 287 ambulatory care, 388–389 bar-coding technology in, 250–251 case management service, 432–433 communication of drug information, 17–18, 182 continuing education, 337, 338 database systems, 76, 287 drug distribution system, 63–64 drug industry marketing to, 64–65 effective technologies, 14 electronic prescribing and, 247 free samples, 18, 19, 65–66, 179, 275, 284–286, 387 in hospitals, 119–120, 367, 369 incidence of medication errors in, 28, 113–114, 119–120, 367, 369, 376, 388–389, 394–395 information kiosks, 205–206 information leaflets, 11–12, 183, 192, 193–196 information resources, 76, 79, 234 Internet and mail-order pharmacies, 64, 388–389 medical school training, 342 medication therapy management, 333–334, 426 multidisciplinary team approach to care, 248 in nursing homes, 376 observation of medication administration, 244 overrides of automated warnings, 251–252, 293 participation in medical rounds, 6, 417 patient education in, 6, 75, 78, 176 patient monitoring, 85–86 pediatric, 394–395 pediatric medicine, 77, 114 point-of-care reference information, 13, 229–232 prescription audits, 244–245 prescription refills, 320, 337 process components, 35, 76–79 recommendations for, 16, 228 recommendations for oversight, 22, 329 research needs, 320 risk/benefit analysis, 17 sources of error in, 75, 76, 77, 78–79 state pharmacy boards, 336–338

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Preventing Medication Errors strategies for improving medication safety, 6, 30–31, 76–78, 222, 224–225, 417–418, 431–433 transcription of prescriptions, 75–76, 378, 394 working environment, 431–432 workload, 176 See also Automated dispensing systems; Computerized provider order entry; Prescribing practice Pictograms, 195–196 Placebo studies, 57 Point-of-care reference information, 13, 229–232 Poison control centers, 202–203 Postmarket surveillance of new drugs, 34, 59–60 Potassium chloride, 279 Prescribing practice in ambulatory care, 314, 385–387, 428–429 assessment of patient medication history, 74 bar-coding technology in, 250–251 best practices, 70 clinical decision making, 71 educational intervention in prescription writing, 428–429 electronic. See Electronic prescribing errors of omission, 373–376 in home care settings, 389–390 in hospitals, 119–120, 367–369 inappropriate use, 71 incidence of medication errors in, 71, 109–110, 112–113, 114–115, 119–120, 314, 367–369, 373–376, 385–387, 393–394 intelligent prompting systems, 295–297 interoperable medication data, 233–236 knowledge base for, 71, 181, 230 length of provider–patient visits and, 184 off-label use, 71 oral orders, 74, 76, 113, 247, 318, 388 overrides of automated warnings, 251, 293 overutilization, 125, 128–129 patient involvement, 70 patient self-prescribing, 74–75 in pediatric care, 320, 393–394 prescriber handwriting, 74 provider profiling and feedback, 425–426 recommendations for improving mediation safety, 16, 228–229, 246 research needs, 320 responsibility, 70 strategies for improving medication safety, 222, 223, 318, 428–429 transcription of prescription, 75–76 types of prescribing errors, 71–74 underutilization, 125, 126–128 See also Computerized provider order entry; Pharmacy practice Preventable adverse drug events in ambulatory care, 124 costs, 5, 130–133 definition, 37, 38 in hospitals, 118–122, 125 incidence, 5, 109–110, 118–125 in long-term care, 125 measurement methodology, 119–120, 123 in nursing homes, 122–123, 313–314 Prevention of medication errors in ambulatory care, 319–320, 428–430 areas of evaluation for improving, 33–34 in care transitions, 8, 14–15, 321–322, 427–428 clinical decision-support system effectiveness, 6, 414–417 computerized order entry effectiveness, 6, 414–417 consumer actions, 163–166 cost/benefit studies, 317–318 criteria for evaluating strategic approaches, 34 in drug administration, 80–81, 83, 250–251 drug effect monitoring, 84–89, 251 drug formulary effectiveness, 129 drug name–related efforts, 278 effective clinical unit characteristics, 222–228 effective use of technologies for, 14, 16, 250–255 evaluation of current efforts, 106 financial incentives, 22, 329 future prospects, 317 in home care setting, 433 in hospitals, 6, 318–319, 409–419

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Preventing Medication Errors interoperable medication data for, 233–236 lessons from other industries, 323–324 in medication-use system, 67 multidisciplinary team approach for, 248–250 in nursing homes, 6, 319, 419–427 obstacles to, 10 opportunities for intervention in drug system, 53 patient monitoring, 85–87 patient self-monitoring for, 87–88 in pediatric care, 320–321, 435 in pharmacy practice, 6, 30–31, 76–78, 222, 224–225, 417–418, 431–433 in prescribing, 71, 222, 223, 318, 428–429 provider education and training for, 342–344 in psychiatric care, 321, 435 recent efforts, 25–26, 29–31 reconciliation for, 14–15, 168–169 regulatory system recommendations, 22, 329 research needs, 2, 20–21, 317–322 risk/benefit information for, 17 role of state pharmacy boards, 336–338 in self-administration of drugs, 83–84, 435–438 in self-care, 433–434 setting-specific strategies, 221–222 stakeholder motivations, 67 stakeholders, 38–39, 50, 150 strategic approaches, 6, 10, 28–29, 150 systemic change for, 143–145, 221 See also Preventable adverse drug events; Provider–patient partnership to prevent medication errors Program of All-Inclusive Care for the Elderly, 250 Proton pump inhibitors, 129 Provider–patient partnership to prevent medication errors, 153–154 attitudinal barriers to, 187–191 barriers to, 179–191 characteristics of reformed health care system, 143–149 communication skills for, 172–173, 182, 183 concept of patient-centered care in, 153–158 consumer empowerment for, 158–162, 163–164 consumer role, 8, 163–166 current state, 152–153 goals, 6–7 knowledge needs for, 181–183 length of provider–patient visits, 184 patient rights, 7–8 provider role, 8–10, 166–179 rationale, 2 recommendations for, 11, 162–163 strategies for strengthening, 151, 153–154 Psychiatric care drug formularies, 129 geriatric medicine, 398–399 medication errors in, 108, 115–116, 313–314, 315, 398–400 medication regulation in nursing homes, 419–423 prevention strategies, 321, 435 research needs, 21, 269, 321 stigma and discrimination in, 190–191 Public opinion, 151–152, 153 Q Quality improvement pathways, 330–333 R Race/ethnicity, consumer health attitudes and beliefs, 189 Reconciliation barriers to implementation, 169 in care transitions, 255 characteristics, 168 effectiveness, 168, 428 electronic data management in, 15, 169 goals, 168 implementation, 169, 255, 428 process, 14, 168–169 rationale, 14 use of interoperable information systems in, 236 Record keeping consumer medication list, 2, 8, 164–165, 234 Continuity of Care Record, 322 electronic, 14

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Preventing Medication Errors errors in ambulatory care settings, 387–388 medication administration record, 8, 81 recommendations, 11, 16, 162, 228 See also Electronic health records; Personal health record Regional Health Information Organizations, 322 Regulation and oversight clinical trials, 63, 159 drug labeling and packaging, 19, 60–62, 193–194, 195, 196, 274–275, 279–280 drug manufacturing and distribution, 63–64, 65–66 drug marketing activities, 62, 64–65 electronic prescribing, 33, 247, 336 guiding principles, 329–330 information technology standards, 334–336 medication therapy management, 333–334 new drug review, 58–59 patient rights, 159, 160 pharmacy practice, 22, 329 for process improvement, 330–333 psychotropic drug use in nursing homes, 419–423 recommendations, 22, 329 See also Food and Drug Administration; Joint Commission on Accreditation of Healthcare Organizations; Surveillance and reporting Religious beliefs, 191 Renal dysfunction, 17, 269 Reporting. See Surveillance and reporting Research ambulatory care, 319–320 costs of medication errors, 129–130, 132–133, 316–317 cross-industry safety studies, 311–324 on data triggers, 322–323 definition of terms for, 311–312 drug formulary effects, 129 drug labeling and packaging, 19 funding, 21, 310, 311 incidence of medication errors, 313–316, 400 international comparison studies, 323 needs, 2, 16, 17, 20–21, 118, 129, 133, 150, 267–271, 311–324, 400 pediatric care, 320–321 prevention strategies, 21, 317–322 recommendations for, 21, 310–311 technology implementation, 319 Research and development, new drug Biologic Licensing Application, 59 clinical trials, 55–57 conflicts of interest in, 57 current state, 55, 56–57, 58 disclosure of results, 57–58, 271–274 effectiveness review, 59 expansion to new indications, 270 fast track approval, 55, 59 generics, 60 goals, 54–55 information management in, 54 manufacturing controls, 63 marketing materials review, 62 New Drug Application, 59 over-the-counter products, 60 in overall drug system, 51 placebo studies, 57 postmarket studies, 34, 59–60, 270, 272 product labeling, 60–62 regulatory oversight, 58–62 risk assessment, 58 safety oversight, 51–53 scope of activities in, 54 shortcomings of current system, 58, 62, 270–271 stages, 55 Respiratory tract infections, 128–129 Rewarding Results, 332 Rofecoxib. See COX-2 inhibitors S Safe Practices for Better Health Care, 222, 227 Schools, health care in, 108, 206, 434–435 medication error incidence, 112, 391 research needs, 314 Self-care consumer’s attitudinal barriers to, 189–191 drug information access and utilization, 181–182 medication errors in, 83, 84, 114, 390–391 medication safety practices, 83–84, 165–166

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Preventing Medication Errors patient-centered Chronic Care Model, 157–158 patient education for, 171, 427 physical impairments to, 185–186 self-monitoring, 87–89 self-prescribing, 74–75 strategies for preventing medication errors in, 419, 433–434 trading/sharing of drugs among consumers, 190, 391 See also Consumer role in preventing medication errors; Nonadherence; Over-the-counter medications Side effects, 186 Smart intravenous pumps alert systems, 293–294 application, 85, 251 effectiveness, 6, 418 medication errors related to, 299–300 research needs, 318, 319 Special populations research needs, 17 See also Geriatric medicine; Pediatric medicine St. John’s Wort, 116 Standardization alert systems, 288, 293–295 bar codes, 288, 290, 297–299 data standards, 20, 287, 288, 324 drug labeling, 280 drug names and abbreviations, 18, 19, 44, 274, 289–293 health information technology, 19–20, 31, 334–336 interoperable medication data, 233–234 medication error terminology, 311–312, 324 medication information leaflets, 12, 192, 195, 200 patient rights, 7–8, 159–160 pediatric dosages, 320 reporting system, 89, 339–340 State governments electronic prescribing laws, 336 informed consent rules, 159 mandatory reporting systems, 89, 91–92 medication error reduction actions, 334 patient rights guarantees, 159–160 pharmacy boards, 336–338 recommendations for, 22, 329 Statins, 129, 315–316 Substance use/abuse, 190–191 Surrogate decision-making, 176–177, 186, 191 Surveillance and reporting administrative databases, 341 chart review for, 241–242 computerized drug event monitors, 30, 85–86, 242–243, 251 confidentiality in, 91 cost/benefit analysis of systems for, 324 current practice in disclosing errors, 152 current programs, 89 data analysis, 245 drug utilization review in ambulatory care, 430 effectiveness, 91 federal systems, 59, 92–94 feedback for reporters, 341–342 goals, 15, 237, 245 institutional systems, 89, 91 interoperable medication data, 234, 236 measurement of medication error incidence and, 109 medication administration errors, 243–244 methods, 15, 237–239 obstacles to, 91, 339 practice-related errors, 340–341 prescription audits, 244–245 rationale, 15, 89, 338–339 recommendations for, 16, 22, 228–229, 236, 329 self-reports for, 237 significance of, 237 standardization of requirements, 89, 339–340 state-mandated, 89, 91–92 strategies for improving current systems, 239–240 strategies to encourage reporting, 339 voluntary systems, 15, 29–30, 89, 92, 239, 240–241 See also Monitoring, patient T Take with Care, 29 Target™stores, 198 Tavistock Group, 160 Telephone helpline effectiveness, 200–201

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Preventing Medication Errors establishing national system of, 202–203 future challenges, 202 providers, 201 recommendations for, 12, 192 services, 201–202 Telephone pharmacy orders. See Prescribing practice, oral orders Thrombosis prophylaxis, 125, 126, 373, 375–376 To Err Is Human: Building a Safer Health System, 2, 25–26, 29 Transcription of prescriptions, 75–76, 378, 394 Transition between care settings research needs, 21, 314, 319, 321–322 risk of medication errors, 112, 384–385 strategies for reducing errors in, 8, 14–15, 321–322, 427–428 technology applications in, 255 use of interoperable information systems in, 235–236 See also Reconciliation Treatment planning consumer attitudes and beliefs and, 189 consumer participation in, 70, 163–164 patient-centered, integrated medication-use system, 143, 144 patient rights, 159, 221 patient self-prescribing, 74–75 provider information needs for, 230 religious beliefs in, 191 surrogate decision-making in, 176–177 U Unit-of-use packaging barriers to implementation, 283 current practice, 77–78, 80, 282–283 definition, 18, 282 forms of, 282 future prospects, 283–284 rationale, 18, 283, 284 recommendations, 19, 274–275 U.S. Pharmacopeia, 89, 91, 240, 245, 279, 341, 429 Utilization of medications among elderly, 86 drug formulary effects, 129 overutilization, 125, 128–129, 234–235, 384 patterns and trends, 1, 31–32 prescription drug sales, 32 review in ambulatory care, 430 underutilization, 125, 126–128, 234–235, 382–384 V Vaccines, 35, 93–94, 279–280, 396–397, 429 Veterans Administration, 66, 89, 335 Vioxx. See COX-2 inhibitors Visual impairment, 184–185 Vitamins, 31, 32, 35 W Warfarin, 88, 249, 382 Withdrawal events in nursing homes, 381–382 World Health Organization, 340

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