National Academies Press: OpenBook

Preventing Medication Errors (2007)

Chapter: Index

« Previous: Appendix D Medication Errors: Prevention Strategies
Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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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

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

data standardization role, 324

recommendations for, 12, 19, 20, 21, 192, 274, 275, 288, 310311

Alerts and alert systems

current technology, 287

false alerts and overrides, 20, 251252, 293294

intelligent prompting, 295297

scope of, 287

severity ranking, 293, 294

standardization, 288, 293295

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, 56, 131, 132

electronic prescribing in, 14, 253

incidence of medication errors, 108, 112114, 124, 314, 384392, 396397

information resources in, 206

medical record keeping in, 387388

medication administration in, 429

medication error detection in, 244

medication therapy management in, 429430

opportunities for patient consultation, 173174

overutilization of medications in, 128

patient monitoring in, 323, 387

pediatric, 396397

preventable ADEs in, 5, 124

prevention research, 319320

research needs, 21, 314, 323

strategies for reducing errors in, 428430

underutilization of medications in, 127128

American Academy of Pediatrics, 29, 434

American Hospital Association, 160

American Medical Association, 410

American Medical Informatics Association, 343344

American Nurses Association, 410

American Society of Health-System Pharmacists, 29, 429

American Society of Hospital Pharmacists, 410

Anesthesia Patient Safety Foundation, 296

Anesthesiology, 296297, 301

Anti-anxiety drugs, 421422

Antibiotic medications, 71, 84, 125, 126, 128, 373, 375

Anticoagulant therapy, 8889, 125, 249, 270, 313314, 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, 7778

B

Bacterial infection prophylaxis, 125, 126.

See also Antibiotic medications

Bar coding, 413

alert systems, 287, 293294

error prevention efficacy, 6, 413

Food and Drug Administration rules, 297298

future prospects, 298299

linkages among automated and computerized systems, 252, 287

in nursing home medication use, 252253

purpose, 14, 30, 81, 250251

regulatory requirements, 280

research needs, 318, 319

standardization, 288, 291, 297299

use interface, 300301

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, 314315

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

right to refuse treatment for dependents, 191

training and support for, 186

Case management, pharmaceutical, 432433

Causes of medication errors and adverse events

areas of evaluation for improving care, 33

in care transitions, 255

communication-related, 1718, 182183, 234, 274, 275

in computerized order entry, 74

in drug administration process, 8183

overutilization, 125, 128129, 274275, 384

in pharmaceutical industry, 266267

in pharmacy practice, 75, 76, 77, 7879

in prescribing process, 7174

research needs, 2, 317

risk/benefit information, 17

scope of, 37, 43, 51, 70

systemic context, 45, 184187

transcription of prescription, 7576, 378, 394

underutilization, 125, 126128, 234235, 382384

user interface-related, 299301

See also Dosage errors;

Nonadherence

Center for Health and Health Care in Schools, 434

Centers for Disease Control and Prevention

adverse event reporting system, 9394

National Center for Health Marketing, 206207

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, 192193, 310311, 312, 329, 333334

role of, 33

Certification Commission on Health Information Technology, 254255

Chart review, 241242

Chemical name, 275

Chemotherapy error incidence, 113

Chronic Care Model, 157158

Chronic coronary disease, 125

Claims data, 341

Clear Rx™, 198

Clinical decision-support systems, 26, 30, 85, 122

current state, 232

effectiveness, 6, 414417

for electronic prescribing, 247248

future prospects, 232

implementation, 253255

intelligent prompting, 295297

overrides of warnings, 251252, 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, 5758, 271274

informed consent rules, 159

new drug development process, 5556

registration site, 271, 272

regulatory oversight, 63

shortcomings of current health system, 17, 5657, 267271

Clinical unit, 222228

ClinicalTrials.gov, 271272

Cochrane Collaboration, 13

Cognitive processing

drug labeling and, 19, 274

medication information leaflet design considerations, 195196, 274

patient with impairment, 185

research needs, 318

technology interface design, 20, 288, 299302

Colds, 128

Comorbodity

adverse event risk, 86

research needs, 17, 269

Complementary and alternative medications

consumer health attitudes and beliefs, 189190

definition, 35

drug interactions, 116

error prevention strategies, 435438

information access for consumers and providers, 182

medication error rate, 108, 116, 316

patient self-prescribing, 7475

research needs, 21, 316

utilization, 31, 32, 189

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

Compliance. See Nonadherence

Computerized drug event monitors, 30, 8586, 242243, 251

Computerized point-of-care reference information, 13, 229232

Computerized prescribing. See Electronic prescribing

Computerized provider order entry, 29, 232

in care transitions, 235236

causes of error in, 300

continuous quality improvement, 255

costs and benefits, 253

effectiveness, 6, 250, 414417

error risk in, 74, 372373, 417

implementation, 222, 253255, 319, 334

implementation trends, 334335

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, 158162, 163

educational interventions to enhance, 29

health literacy and, 182183

identifying information resources, 166

medication list maintenance, 2, 8, 164165, 234

medication safety practices, 165166

multidisciplinary team approach to care, 248

recommendations for enhancing, 11, 162163

research needs, 21, 312

treatment planning, 70, 163164

use and understanding of drug labels, 75

See also Provider–patient partnership to prevent medication errors

Continuing medical education

for information technology, 343344

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, 132133

medication spending, 202

medication therapy management, 333

observation of medication administration, 244

as obstacle to care, 10, 186187

patterns and trends, 32

prescription drug sales, 32

risk-benefit analysis of medication use, 267268

Costs

free drug sample distribution, 284

of medication error prevention strategies, 317318

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, 130133

data sources, 2, 129130

preventable adverse drug events, 56

research needs, 2, 5, 6, 21, 133, 316317

COX-2 inhibitors, 32, 268, 272

Crossing the Quality Chasm: A New Health System for the 21st Century, 6, 26, 143144

Cultural factors

barriers to provider–patient partnership, 187191

culture of safety, 1516, 187, 222, 255, 318

language conflict, 183

obstacles to prevention of medication errors, 10

patient-centered, integrated medication-use system, 143145

recent efforts to promote safe care, 3031

D

DailyMed program, 12, 192, 200

Decision-support systems. See Clinical decision-support systems

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

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, 175176, 235

Distractions as source of medication error

in drug administration, 8283

in pharmacy, 79, 431432

Diuretic drugs, 313314

Dosage errors

clinical knowledge base, 269270

electronic prescribing to prevent, 246

over-the-counter drugs, 116

pediatric, 320

in pediatric care, 392393, 394

preventable ADEs, 119, 123, 124

preventing in drug administration process, 80

in self-administration of drugs, 8384

standardization to prevent, 320

types of errors, 7172, 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, 7677

preventable ADEs in hospitals, 119

risk, 71, 72, 88, 386387

Drug names and abbreviations

brand names, 277, 278

chemical names, 275

current practice, 275277, 280

generic drugs, 275277, 278

official title, 277

as source of prescribing error, 7172, 82, 275

standardization, 18, 19, 44

Drug resistance, 71, 128

Drug system

barriers to improvement, 179180

current shortcomings, 5354, 6769, 90

manufacturing controls, 63

medication-use system, 6670, 89, 90

number of pharmaceutical agents, 51

opportunities for intervention, 53, 67

principles for safe practice in, 5051, 53

stages of drug development and delivery, 51

stakeholders, 50, 67

standards, 53

structure and operations, 5153

systemic context of errors, 45, 5354, 184187

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, 423425

prescription writing aids, 428429

profiling and feedback, 425426

recommendations, 344

safety courses and resources, 343

shortcomings of current system, 342343

for use of information technology, 343344, 427

See also Continuing medical education

Educational interventions

with caregivers, 186

communication skills for, 172173, 182, 183

consumer health literacy, 182183

core information, 172

at discharge, 175176, 235

effectiveness, 6, 419

to enhance patient self-care, 163164, 427, 433434

obstacles to prevention of medication errors, 10

opportunities for consultation, 173176

provider actions to improve medication safety, 8, 10, 171172

provider training for, 171

recent efforts, 29

recommendations, 11, 1213, 162, 192193

self-management support, 158

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

shortcomings of current system, 1112, 179, 181183

See also Information resources

Electronic ADE detection, 242243

Electronic health records

certification, 254255

data standards, 289

error risk, 372373

implementation trends, 334335, 2044

purpose, 203204, 222, 253

standardization, 336

Electronic prescribing, 30

decision support rules, 247248

implementation challenges, 1314

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, 228229, 246

regulatory restrictions, 247

standardization, 335

state regulation, 336

Emergency departments

cost of admissions related to prior ADEs, 130131

medication error rates, 114115, 397

overutilization of antibiotics in, 128

pediatric, 114115, 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, 9294

information technology role, 334

patient rights guarantees, 159160

recommendations for, 1113

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, 297298

clinical trials oversight, 159

drug labeling and packaging oversight, 19, 6062, 193194, 195, 196, 274275, 279280

drug manufacturing and distribution oversight, 63

drug name selection process, 278, 280

drug safety activities, 3233, 5153

error reporting systems, 89

information dissemination role, 29, 207, 312

in new drug development, 51, 55, 56, 5860

recommendations for, 12, 19, 21, 192193, 274275, 310311

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, 6566, 179, 275, 285287, 387

G

Generic drugs

free samples, 285287

naming conventions, 275277, 278

Geriatric medicine

adherence, physical impairment and, 184185

clinical knowledge base, 268269

cost of care, 187

drug information access and utilization, 181

health system trends, 32

medication regulation in nursing homes, 419423

multidisciplinary team approach to care, 250

patient monitoring in, 86

psychotropic medications, 398399, 419423

risk of medication error, 17, 57, 86, 313314, 398399

See also Nursing homes

H

Hand-offs. See Transition between care settings

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

Health care providers

access to information, 181, 231232

actions to improve medication safety, 810

attitudinal barriers to provider–patient partnership, 187189

disclosure of errors to patients, 160162, 177179

drug industry marketing to, 65

effective clinical units, 222228

handwriting, 74

information needs, 229231

integration of complementary and alternative medications, 189190

interpersonal skills, 171173, 178

medication reconciliation, 1415, 168169

multidisciplinary teams, 248250

opportunities for patient consultation, 173176

patient education role, 171173

performance measurement, 330331

public opinion, 151152, 153

recommendations for, 22, 248, 329

reporting behaviors, 152

scope of, 38

workforce development, 342344

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, 389390, 433.

See also Ambulatory care;

Transition between care settings

Hormone replacement therapy, 267268

Hospital Incident Reporting Ontology, 340

Hospitals

computerized order entry in, 253254

costs of ADEs in, 130132

drug repackaging, 77

incidence of medication errors and ADEs, 12, 4, 5, 108111, 118122, 125, 313, 323, 367376

opportunities for patient consultation, 174176

performance assessment, 341

psychiatric, 399

research needs, 318319

strategies for preventing medication errors and ADEs, 6, 318319, 409419

underutilization of medications in, 125, 126127

Human factors design

drug labeling, 19, 274

medication information leaflets, 195196, 274

significance of, 50

technology interface, 20, 288, 299302

Hypertension management, 127, 268

I

Ibuprofen, 31

Incidence of medication errors and ADEs

adherence-related errors, 86, 114, 179, 390391

in ambulatory care, 108, 112114, 124, 314, 384392, 396397

areas of evaluation for improving care, 33

in chronic illness, 86

in complementary and alternative

medication use, 108, 116, 316

current estimates, 12, 28, 116118

data sources, 105108

definition of medication error and, 311

detection methods, 4

in drug administration, 4, 28, 110112, 114115, 369371, 376378, 395396

in emergency care, 114115, 397

errors of omission, 28, 108, 373376

in geriatric medicine, 86, 398399

in home care pharmacy, 389390

in hospitals, 12, 4, 5, 108111, 118122, 125, 313, 323, 367376

in mail-order pharmacy, 388389

measurement methodologies, 109

in medication-use process, 109

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

in nursing homes, 108, 111112, 122123, 313314, 376384

in over-the-counter drug use, 108, 116, 315

overutilization errors, 125, 128129, 384

patient monitoring errors, 86, 371, 373, 378

in pediatric care, 4, 108, 114115, 314315, 393398

in pharmacy practice, 28, 113114, 367, 369, 376, 388389, 394395

in prescribing, 71, 109110, 112113, 114115, 314, 367369, 373376, 385387, 393394

preventable adverse drug events, 5, 118125, 109110

in primary care, 86

in psychiatric care settings, 108, 115116, 315, 398400

research needs, 2, 3, 21, 118, 313316, 400

in school health care, 112, 391

in self care, 114, 390391

underutilization errors, 125, 126128, 382384

in use of over-the-counter drugs, 108, 116, 315

variation across facilities, 4, 117

Industry, pharmaceutical, 38

communication of drug information, 1718, 183, 266267

drug formularies, 66

free sample distribution, 18, 19, 6566, 179, 275, 284286, 387

manufacturing oversight, 63

potential sources of medication error in, 51, 266

product recalls, 51

recommendations for, 1819, 20, 274275, 287288

role in improving medication safety, 150, 266267

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, 267271

consumer access, 205

consumer behavior, 75

consumer demand, 165166

current publishing system, 271272

current technologies, 286287

data standards, 20, 287, 288

design considerations, 195196

drug labeling and packaging, 1719, 183

drug risk/benefit information, 17

goals, 205

government role, 334

integration of technologies, 287

international comparison studies, 323

Internet, 1112, 198200

interoperable medication data, 233236

medication information leaflets, 1112, 183, 192, 193196

for medication reconciliation, 1415, 168169

minimum functionality standards for technology, 22, 329, 334336

in new drug development process, 54

patient safety educational materials for providers, 343

for patient self-prescribing, 7475

for pharmacists, 76, 79, 234

pharmacy database, 76, 287

point-of-care reference information, 13, 229232

for preventing drug administration errors, 83

proposal for national registry, 272274

provider access systems, 231232

provider needs, 229231

publication bias, 272

recommendations for improving, 1213, 16, 20, 192193, 228229, 274275, 287288

research to enhance consumer use and comprehension, 312

reward for investment in, 331

shortcomings of current system, 1112, 1718, 181183, 267, 271272

standardization of health information technology, 1920, 31, 289293

structure and scope of national medication safety system, 205207

technology interface design, 299302

technology training for providers, 343344, 427

telephone helpline, 12, 192, 200203

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

See also Alerts and alert systems;

Educational interventions;

Surveillance and reporting

Informed consent, 159

Institute for Healthcare Improvement, 2526, 157, 168169

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, 186187

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, 198199

National Library of Medicine programs, 199200

online pharmacies, 64, 199

quality of health information on, 1112, 199

recommendations for, 12, 192

Intravenous medication

administration errors, 110, 370, 371

causes of error in, 299300

error prevention technologies, 251

See also Smart intravenous pumps

J

Joint Commission on Accreditation of Healthcare Organizations, 2526

data standardization activities, 324, 340

National Patient Safety Goals, 31, 222, 225226, 337

patient rights oversight, 159, 160

reconciliation standards, 169

Sentinel Event Policy, 2930, 91, 410

K

Katrinahealth.org, 233234

L

Labeling and packaging

black box warnings, 61

consumer use and understanding, 75

container labels, 196198

drug interaction data, 87

drug samples, 387

over-the-counter medications, 61, 438

recommendations for, 1819, 274275

regulatory oversight, 6062, 193194, 195, 196, 278279

shortcomings of current system, 1718, 194, 196198, 275, 276277, 278280

as source of medication error, 45, 77, 79, 267, 275

strategies for improving, 198, 280, 281282

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, 9192

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, 388389

legal status, 64

operations, 64

research needs, 314

Managed care organization drug formularies, 129

Marketing and distribution of drugs

distribution system, 6364

free drug samples, 1819, 19, 6566, 179, 275, 284286

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

industry spending on promotion, 64, 65

marketing effects, 65

in overall drug system, 51

promotional techniques, 6465

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, 333334

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, 4349, 152153

cause for concern, 1, 2628

costs. See Cost(s) of medication errors

definition, 3, 3637, 311312

detection methods, 237239, 241245

disclosure, 160162, 177179

frequency. See Incidence of medication errors and ADEs

mortality, 25

preventability, 2

public perception, 151152

reporting. See Surveillance and reporting

research needs, 2, 150, 310

settings, 34, 28, 35, 6769

types of products involved in, 35, 6769

See also Adverse drug events

Medication Modernization Act, 33

Medication Safety Alert newsletter, 240

Medication therapy management, 22, 329, 333334, 426, 429430

Medline Plus, 12, 192, 199200

MedMARx Program, 89, 240, 245

MedWatch program, 61, 89, 92, 340341

Microsoft, 301

Monitoring, patient

in ambulatory care, 323, 387

chart review, 241242

computerized drug event monitors, 30, 8586, 242243, 251

errors in nursing homes, 112, 378

errors in pediatric care, 396

goals, 2, 15, 84, 8687

intelligent prompting systems, 295297

methods and technologies, 84, 85

observation of medication administration, 243244

patient self-monitoring, 8789

pharmacist role, 8586

preventable ADEs related to, 371, 373

provider knowledge for, 87

recommendations for, 16, 228

research needs, 322323

responsibility, 84

scope, 8485

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, 248250

Myocardial infarction, 125, 126, 127, 382

N

National Academy for State Health Policy, 91, 92

National Center for Health Marketing, 206207

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, 199200

recommendations for, 12, 20, 21, 192193, 274, 287, 312

National Nosocomial Infection Survey, 91

National Quality Forum, 29, 30, 222, 227, 331

National Voluntary Consensus Standards for Ambulatory Care, 332

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

Near miss, 311312

New Drug Application, 59, 270271

Nonadherence

causes of, 179, 184

cognitive impairment and, 185

consumer health attitudes and beliefs and, 189

cost of care and, 186187

costs of, 6

definition, 179

drug side effects as cause of, 186

incidence, 86, 114, 179, 390391

interventions to prevent, 434

physical impairment as cause of, 184185

provider–consumer communication and, 182

Nursing

adequate staffing, 30

case example of medication error, 4345

drug administration procedure, 7980

drug effect monitoring responsibility, 84

education programs for nurses, 342

educational interventions in nursing homes, 423, 424425

home health care, 390

interpersonal skill training, 172

observation of medication administration, 243244

strategies for improving medication safety, 80, 222, 225

workload issues, 82

Nursing homes

automated and computerized medication-use technologies for, 14, 252253

costs of medication errors in, 131

drug administration in, 376378

incidence of medication errors and ADEs, 108, 111112, 122123, 313314, 376384

overutilization errors, 384

research needs, 319

strategies for preventing medication errors and ADEs, 6, 319, 419427

underutilization of medications in, 127, 382384

workforce education, 423425

See also Long-term care

O

Official title of medication, 277

Off-label use, 71, 268

Omnibus Budget Reconciliation Act, 419420, 421422, 423

Organizational psychology, 50

Orphan drugs, 77

Osteoporosis, 125, 127, 382

Outpatient care. See Ambulatory care

Overdose

case example, 4345

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, 315316

dosing errors, 83

incidence of medication errors, 108, 116, 315

label warnings, 61, 438

patient self-prescribing, 7475

regulatory review, 60

research needs, 21, 315316

scope of, 51

self-monitoring when using, 8788

strategies for error prevention, 435438

utilization, 31

P

Pain management, 125, 127, 382384

Patient-centered care

attitudinal barriers to, 188189

characteristics of organizational culture based on, 188

conceptual model, 157158

consumer empowerment in, 158162, 163164

consumer expectations, 153

essential elements, 153155, 156

goals for, 143150

provider responsibilities, 166

quality of communications in, 155, 172173

rationale, 155157

self-management support in, 157158

See also Provider–patient partnership to prevent medication errors

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

Patient rights

clinical significance, 7, 158

current standards, 78, 159160

to disclosure of adverse events, 7, 160162, 177179

informed consent, 159

pharmacy consultation, 176

provider responsibility, 810

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, 244245, 339, 340

Patient Safety Event Taxonomy, 324, 340

Pediatric medicine

caregiver error in fever treatment, 116

clinical knowledge base, 268

emergency care, 397

immunizations, 396397

incidence of medication error, 4, 108, 114115, 314315, 393398

medication error risk, 17

patient monitoring, 396

pharmacy practice, 77, 114

prescribing practice, 393394

research needs, 320321

strategies for medication error prevention, 320321, 435

surrogate decision-making, 191

People’s Medical Society, 29

Performance measurement, 341

pathways to quality improvement, 330331

pay-for-performance systems, 331333

Personal health record

consumer self-management and, 312313

current state, 203204

essential components, 204205

interoperable medication data, 233236

minimum data set, 12, 193, 312

rationale, 203204

recommendations for, 12, 16, 193, 228

reconciliation in care transitions, 1415, 168169

types of, 204

vendor responsibilities, 12

See also Electronic health records

Pharmacy benefits manager, 64

Pharmacy practice

alert systems, 287

ambulatory care, 388389

bar-coding technology in, 250251

case management service, 432433

communication of drug information, 1718, 182

continuing education, 337, 338

database systems, 76, 287

drug distribution system, 6364

drug industry marketing to, 6465

effective technologies, 14

electronic prescribing and, 247

free samples, 18, 19, 6566, 179, 275, 284286, 387

in hospitals, 119120, 367, 369

incidence of medication errors in, 28, 113114, 119120, 367, 369, 376, 388389, 394395

information kiosks, 205206

information leaflets, 1112, 183, 192, 193196

information resources, 76, 79, 234

Internet and mail-order pharmacies, 64, 388389

medical school training, 342

medication therapy management, 333334, 426

multidisciplinary team approach to care, 248

in nursing homes, 376

observation of medication administration, 244

overrides of automated warnings, 251252, 293

participation in medical rounds, 6, 417

patient education in, 6, 75, 78, 176

patient monitoring, 8586

pediatric, 394395

pediatric medicine, 77, 114

point-of-care reference information, 13, 229232

prescription audits, 244245

prescription refills, 320, 337

process components, 35, 7679

recommendations for, 16, 228

recommendations for oversight, 22, 329

research needs, 320

risk/benefit analysis, 17

sources of error in, 75, 76, 77, 7879

state pharmacy boards, 336338

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

strategies for improving medication safety, 6, 3031, 7678, 222, 224225, 417418, 431433

transcription of prescriptions, 7576, 378, 394

working environment, 431432

workload, 176

See also Automated dispensing systems;

Computerized provider order entry;

Prescribing practice

Pictograms, 195196

Placebo studies, 57

Point-of-care reference information, 13, 229232

Poison control centers, 202203

Postmarket surveillance of new drugs, 34, 5960

Potassium chloride, 279

Prescribing practice

in ambulatory care, 314, 385387, 428429

assessment of patient medication history, 74

bar-coding technology in, 250251

best practices, 70

clinical decision making, 71

educational intervention in prescription writing, 428429

electronic. See Electronic prescribing

errors of omission, 373376

in home care settings, 389390

in hospitals, 119120, 367369

inappropriate use, 71

incidence of medication errors in, 71, 109110, 112113, 114115, 119120, 314, 367369, 373376, 385387, 393394

intelligent prompting systems, 295297

interoperable medication data, 233236

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, 128129

patient involvement, 70

patient self-prescribing, 7475

in pediatric care, 320, 393394

prescriber handwriting, 74

provider profiling and feedback, 425426

recommendations for improving mediation safety, 16, 228229, 246

research needs, 320

responsibility, 70

strategies for improving medication safety, 222, 223, 318, 428429

transcription of prescription, 7576

types of prescribing errors, 7174

underutilization, 125, 126128

See also Computerized provider order entry;

Pharmacy practice

Preventable adverse drug events

in ambulatory care, 124

costs, 5, 130133

definition, 37, 38

in hospitals, 118122, 125

incidence, 5, 109110, 118125

in long-term care, 125

measurement methodology, 119120, 123

in nursing homes, 122123, 313314

Prevention of medication errors

in ambulatory care, 319320, 428430

areas of evaluation for improving, 3334

in care transitions, 8, 1415, 321322, 427428

clinical decision-support system effectiveness, 6, 414417

computerized order entry effectiveness, 6, 414417

consumer actions, 163166

cost/benefit studies, 317318

criteria for evaluating strategic approaches, 34

in drug administration, 8081, 83, 250251

drug effect monitoring, 8489, 251

drug formulary effectiveness, 129

drug name–related efforts, 278

effective clinical unit characteristics, 222228

effective use of technologies for, 14, 16, 250255

evaluation of current efforts, 106

financial incentives, 22, 329

future prospects, 317

in home care setting, 433

in hospitals, 6, 318319, 409419

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

interoperable medication data for, 233236

lessons from other industries, 323324

in medication-use system, 67

multidisciplinary team approach for, 248250

in nursing homes, 6, 319, 419427

obstacles to, 10

opportunities for intervention in drug system, 53

patient monitoring, 8587

patient self-monitoring for, 8788

in pediatric care, 320321, 435

in pharmacy practice, 6, 3031, 7678, 222, 224225, 417418, 431433

in prescribing, 71, 222, 223, 318, 428429

provider education and training for, 342344

in psychiatric care, 321, 435

recent efforts, 2526, 2931

reconciliation for, 1415, 168169

regulatory system recommendations, 22, 329

research needs, 2, 2021, 317322

risk/benefit information for, 17

role of state pharmacy boards, 336338

in self-administration of drugs, 8384, 435438

in self-care, 433434

setting-specific strategies, 221222

stakeholder motivations, 67

stakeholders, 3839, 50, 150

strategic approaches, 6, 10, 2829, 150

systemic change for, 143145, 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, 153154

attitudinal barriers to, 187191

barriers to, 179191

characteristics of reformed health care system, 143149

communication skills for, 172173, 182, 183

concept of patient-centered care in, 153158

consumer empowerment for, 158162, 163164

consumer role, 8, 163166

current state, 152153

goals, 67

knowledge needs for, 181183

length of provider–patient visits, 184

patient rights, 78

provider role, 810, 166179

rationale, 2

recommendations for, 11, 162163

strategies for strengthening, 151, 153154

Psychiatric care

drug formularies, 129

geriatric medicine, 398399

medication errors in, 108, 115116, 313314, 315, 398400

medication regulation in nursing homes, 419423

prevention strategies, 321, 435

research needs, 21, 269, 321

stigma and discrimination in, 190191

Public opinion, 151152, 153

Q

Quality improvement pathways, 330333

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, 168169

rationale, 14

use of interoperable information systems in, 236

Record keeping

consumer medication list, 2, 8, 164165, 234

Continuity of Care Record, 322

electronic, 14

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

errors in ambulatory care settings, 387388

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, 6062, 193194, 195, 196, 274275, 279280

drug manufacturing and distribution, 6364, 6566

drug marketing activities, 62, 6465

electronic prescribing, 33, 247, 336

guiding principles, 329330

information technology standards, 334336

medication therapy management, 333334

new drug review, 5859

patient rights, 159, 160

pharmacy practice, 22, 329

for process improvement, 330333

psychotropic drug use in nursing homes, 419423

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, 319320

costs of medication errors, 129130, 132133, 316317

cross-industry safety studies, 311324

on data triggers, 322323

definition of terms for, 311312

drug formulary effects, 129

drug labeling and packaging, 19

funding, 21, 310, 311

incidence of medication errors, 313316, 400

international comparison studies, 323

needs, 2, 16, 17, 2021, 118, 129, 133, 150, 267271, 311324, 400

pediatric care, 320321

prevention strategies, 21, 317322

recommendations for, 21, 310311

technology implementation, 319

Research and development, new drug

Biologic Licensing Application, 59

clinical trials, 5557

conflicts of interest in, 57

current state, 55, 5657, 58

disclosure of results, 5758, 271274

effectiveness review, 59

expansion to new indications, 270

fast track approval, 55, 59

generics, 60

goals, 5455

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, 5960, 270, 272

product labeling, 6062

regulatory oversight, 5862

risk assessment, 58

safety oversight, 5153

scope of activities in, 54

shortcomings of current system, 58, 62, 270271

stages, 55

Respiratory tract infections, 128129

Rewarding Results, 332

Rofecoxib. See COX-2 inhibitors

S

Safe Practices for Better Health Care, 222, 227

Schools, health care in, 108, 206, 434435

medication error incidence, 112, 391

research needs, 314

Self-care

consumer’s attitudinal barriers to, 189191

drug information access and utilization, 181182

medication errors in, 83, 84, 114, 390391

medication safety practices, 8384, 165166

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

patient-centered Chronic Care Model, 157158

patient education for, 171, 427

physical impairments to, 185186

self-monitoring, 8789

self-prescribing, 7475

strategies for preventing medication errors in, 419, 433434

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, 293294

application, 85, 251

effectiveness, 6, 418

medication errors related to, 299300

research needs, 318, 319

Special populations

research needs, 17

See also Geriatric medicine;

Pediatric medicine

St. John’s Wort, 116

Standardization

alert systems, 288, 293295

bar codes, 288, 290, 297299

data standards, 20, 287, 288, 324

drug labeling, 280

drug names and abbreviations, 18, 19, 44, 274, 289293

health information technology, 1920, 31, 334336

interoperable medication data, 233234

medication error terminology, 311312, 324

medication information leaflets, 12, 192, 195, 200

patient rights, 78, 159160

pediatric dosages, 320

reporting system, 89, 339340

State governments

electronic prescribing laws, 336

informed consent rules, 159

mandatory reporting systems, 89, 9192

medication error reduction actions, 334

patient rights guarantees, 159160

pharmacy boards, 336338

recommendations for, 22, 329

Statins, 129, 315316

Substance use/abuse, 190191

Surrogate decision-making, 176177, 186, 191

Surveillance and reporting

administrative databases, 341

chart review for, 241242

computerized drug event monitors, 30, 8586, 242243, 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, 9294

feedback for reporters, 341342

goals, 15, 237, 245

institutional systems, 89, 91

interoperable medication data, 234, 236

measurement of medication error incidence and, 109

medication administration errors, 243244

methods, 15, 237239

obstacles to, 91, 339

practice-related errors, 340341

prescription audits, 244245

rationale, 15, 89, 338339

recommendations for, 16, 22, 228229, 236, 329

self-reports for, 237

significance of, 237

standardization of requirements, 89, 339340

state-mandated, 89, 9192

strategies for improving current systems, 239240

strategies to encourage reporting, 339

voluntary systems, 15, 2930, 89, 92, 239, 240241

See also Monitoring, patient

T

Take with Care, 29

Target™stores, 198

Tavistock Group, 160

Telephone helpline

effectiveness, 200201

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

establishing national system of, 202203

future challenges, 202

providers, 201

recommendations for, 12, 192

services, 201202

Telephone pharmacy orders. See Prescribing practice, oral orders

Thrombosis prophylaxis, 125, 126, 373, 375376

To Err Is Human: Building a Safer Health System, 2, 2526, 29

Transcription of prescriptions, 7576, 378, 394

Transition between care settings

research needs, 21, 314, 319, 321322

risk of medication errors, 112, 384385

strategies for reducing errors in, 8, 1415, 321322, 427428

technology applications in, 255

use of interoperable information systems in, 235236

See also Reconciliation

Treatment planning

consumer attitudes and beliefs and, 189

consumer participation in, 70, 163164

patient-centered, integrated medication-use system, 143, 144

patient rights, 159, 221

patient self-prescribing, 7475

provider information needs for, 230

religious beliefs in, 191

surrogate decision-making in, 176177

U

Unit-of-use packaging

barriers to implementation, 283

current practice, 7778, 80, 282283

definition, 18, 282

forms of, 282

future prospects, 283284

rationale, 18, 283, 284

recommendations, 19, 274275

U.S. Pharmacopeia, 89, 91, 240, 245, 279, 341, 429

Utilization of medications

among elderly, 86

drug formulary effects, 129

overutilization, 125, 128129, 234235, 384

patterns and trends, 1, 3132

prescription drug sales, 32

review in ambulatory care, 430

underutilization, 125, 126128, 234235, 382384

V

Vaccines, 35, 9394, 279280, 396397, 429

Veterans Administration, 66, 89, 335

Vioxx. See COX-2 inhibitors

Visual impairment, 184185

Vitamins, 31, 32, 35

W

Warfarin, 88, 249, 382

Withdrawal events in nursing homes, 381382

World Health Organization, 340

Suggested Citation:"Index." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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Preventing Medication Errors Get This Book
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In 1996 the Institute of Medicine launched the Quality Chasm Series, a series of reports focused on assessing and improving the nation’s quality of health care. Preventing Medication Errors is the newest volume in the series. Responding to the key messages in earlier volumes of the series—To Err Is Human (2000), Crossing the Quality Chasm (2001), and Patient Safety (2004)—this book sets forth an agenda for improving the safety of medication use. It begins by providing an overview of the system for drug development, regulation, distribution, and use. Preventing Medication Errors also examines the peer-reviewed literature on the incidence and the cost of medication errors and the effectiveness of error prevention strategies. Presenting data that will foster the reduction of medication errors, the book provides action agendas detailing the measures needed to improve the safety of medication use in both the short- and long-term. Patients, primary health care providers, health care organizations, purchasers of group health care, legislators, and those affiliated with providing medications and medication- related products and services will benefit from this guide to reducing medication errors.

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