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
Acute care
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
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
research needs, 21
responsibility, 79
Adverse drug events (ADEs)
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
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
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
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
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
Antibiotic medications, 71, 84, 125, 126, 128, 373, 375
Anticoagulant therapy, 88–89, 125, 249, 270, 313–314, 382
Associated in Process Improvement, 157
Atrial fibrillation, 125, 127, 382
Automated dispensing systems
implementation, 334
linkages among automated and computerized systems, 252, 287
overrides of warnings, 252
B
Bacterial infection prophylaxis, 125, 126.
See also Antibiotic medications
Bar coding, 413
error prevention efficacy, 6, 413
Food and Drug Administration rules, 297–298
linkages among automated and computerized systems, 252, 287
in nursing home medication use, 252–253
regulatory requirements, 280
standardization, 288, 291, 297–299
Best Pharmaceuticals Act for Children, 268
Biologic Licensing Application, 59
Biologic products, 35
Blood and blood products, 35
Bridges to Excellence, 331
Bronchitis, 128
C
Cancer treatment, 164
Caregivers
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
risk/benefit information, 17
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
Chemical name, 275
Chemotherapy error incidence, 113
Chronic coronary disease, 125
Claims data, 341
Clear Rx™, 198
Clinical decision-support systems, 26, 30, 85, 122
current state, 232
for electronic prescribing, 247–248
future prospects, 232
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
regulatory oversight, 63
shortcomings of current health system, 17, 56–57, 267–271
Cochrane Collaboration, 13
Cognitive processing
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
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
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
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
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
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
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
Continuity of Care Record, 322
Coronary artery disease, 128
Cost of care
computerized order entry, 253
considerations in treatment planning, 70
containment efforts, 32
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
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
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
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
Drug names and abbreviations
chemical names, 275
current practice, 275–277, 280
official title, 277
as source of prescribing error, 71–72, 82, 275
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
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
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
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
shortcomings of current system, 11–12, 179, 181–183
See also Information resources
Electronic ADE detection, 242–243
Electronic health records
data standards, 289
implementation trends, 334–335, 2044
standardization, 336
Electronic prescribing, 30
decision support rules, 247–248
implementation challenges, 13–14
linkages among automated and computerized systems, 252, 287
in outpatient care, 253
oversight and implementation, 33
potential for error, 248
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
Errors of omission, 5, 26, 28, 36, 69, 108
F
Failure modes and effects analysis, 278
Federal government
adverse event reporting and surveillance system, 92–94
information technology role, 334
patient rights guarantees, 159–160
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
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
effects on safety, 129
effects on utilization, 129
Free drug samples, 18, 19, 65–66, 179, 275, 285–287, 387
G
Generic drugs
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
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
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
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
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
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
strategies for preventing medication errors and ADEs, 6, 318–319, 409–419
underutilization of medications in, 125, 126–127
Human factors design
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
current estimates, 1–2, 28, 116–118
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
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
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
consumer access, 205
consumer behavior, 75
current publishing system, 271–272
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
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
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
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
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
consumer health behaviors, 198–199
National Library of Medicine programs, 199–200
quality of health information on, 11–12, 199
Intravenous medication
administration errors, 110, 370, 371
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
L
Labeling and packaging
black box warnings, 61
consumer use and understanding, 75
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
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
legal status, 64
operations, 64
research needs, 314
Managed care organization drug formularies, 129
Marketing and distribution of drugs
industry spending on promotion, 64, 65
marketing effects, 65
in overall drug system, 51
shortcomings of current system, 66
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
costs. See Cost(s) of medication errors
detection methods, 237–239, 241–245
frequency. See Incidence of medication errors and ADEs
mortality, 25
preventability, 2
reporting. See Surveillance and reporting
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
MedWatch program, 61, 89, 92, 340–341
Microsoft, 301
Monitoring, patient
computerized drug event monitors, 30, 85–86, 242–243, 251
errors in nursing homes, 112, 378
errors in pediatric care, 396
intelligent prompting systems, 295–297
methods and technologies, 84, 85
observation of medication administration, 243–244
patient self-monitoring, 87–89
preventable ADEs related to, 371, 373
provider knowledge for, 87
responsibility, 84
See also Alerts and alert systems;
Computerized drug event monitors;
Surveillance and reporting
Monoamine oxidase inhibitors, 88
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
New Drug Application, 59, 270–271
Nonadherence
cognitive impairment and, 185
consumer health attitudes and beliefs and, 189
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
See also Long-term care
O
Official title of medication, 277
Omnibus Budget Reconciliation Act, 419–420, 421–422, 423
Organizational psychology, 50
Orphan drugs, 77
Outpatient care. See Ambulatory care
Overdose
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
patient self-prescribing, 74–75
regulatory review, 60
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
consumer empowerment in, 158–162, 163–164
consumer expectations, 153
essential elements, 153–155, 156
provider responsibilities, 166
quality of communications in, 155, 172–173
self-management support in, 157–158
See also Provider–patient partnership to prevent medication errors
Patient rights
current standards, 7–8, 159–160
to disclosure of adverse events, 7, 160–162, 177–179
informed consent, 159
pharmacy consultation, 176
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
incidence of medication error, 4, 108, 114–115, 314–315, 393–398
medication error risk, 17
patient monitoring, 396
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
interoperable medication data, 233–236
minimum data set, 12, 193, 312
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
bar-coding technology in, 250–251
case management service, 432–433
communication of drug information, 17–18, 182
continuing education, 337, 338
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 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
point-of-care reference information, 13, 229–232
prescription refills, 320, 337
recommendations for oversight, 22, 329
research needs, 320
risk/benefit analysis, 17
strategies for improving medication safety, 6, 30–31, 76–78, 222, 224–225, 417–418, 431–433
transcription of prescriptions, 75–76, 378, 394
workload, 176
See also Automated dispensing systems;
Computerized provider order entry;
Prescribing practice
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
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
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
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
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
future prospects, 317
in home care setting, 433
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 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
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
setting-specific strategies, 221–222
stakeholder motivations, 67
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
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
length of provider–patient visits, 184
rationale, 2
recommendations for, 11, 162–163
strategies for strengthening, 151, 153–154
Psychiatric care
drug formularies, 129
medication errors in, 108, 115–116, 313–314, 315, 398–400
medication regulation in nursing homes, 419–423
prevention strategies, 321, 435
stigma and discrimination in, 190–191
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
electronic data management in, 15, 169
goals, 168
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
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
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
information technology standards, 334–336
medication therapy management, 333–334
for process improvement, 330–333
psychotropic drug use in nursing homes, 419–423
See also Food and Drug Administration;
Joint Commission on Accreditation of Healthcare Organizations;
Surveillance and reporting
Religious beliefs, 191
Reporting. See Surveillance and reporting
Research
costs of medication errors, 129–130, 132–133, 316–317
cross-industry safety studies, 311–324
definition of terms for, 311–312
drug formulary effects, 129
drug labeling and packaging, 19
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
prevention strategies, 21, 317–322
recommendations for, 21, 310–311
technology implementation, 319
Research and development, new drug
Biologic Licensing Application, 59
conflicts of interest in, 57
disclosure of results, 57–58, 271–274
effectiveness review, 59
expansion to new indications, 270
generics, 60
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
risk assessment, 58
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
patient-centered Chronic Care Model, 157–158
patient education for, 171, 427
physical impairments to, 185–186
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
medication errors related to, 299–300
Special populations
research needs, 17
See also Geriatric medicine;
Pediatric medicine
St. John’s Wort, 116
Standardization
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
pediatric dosages, 320
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
Surrogate decision-making, 176–177, 186, 191
Surveillance and reporting
administrative databases, 341
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
feedback for reporters, 341–342
interoperable medication data, 234, 236
measurement of medication error incidence and, 109
medication administration errors, 243–244
practice-related errors, 340–341
recommendations for, 16, 22, 228–229, 236, 329
self-reports for, 237
significance of, 237
standardization of requirements, 89, 339–340
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
establishing national system of, 202–203
future challenges, 202
providers, 201
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 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
forms of, 282
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
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
W
Withdrawal events in nursing homes, 381–382
World Health Organization, 340