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| Defining the Issues | |
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| Definitions | |
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| Types of Medication Incidents | |
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| Studies of Patient Safety | |
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| The Impact of Adverse Drug Events and Medication Errors | |
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| Summary | |
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| Reflective Questions | |
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| Why Medication Incidents Occur | |
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| Error Theory | |
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| Studies of Contributory Factors | |
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| Classification of Contributory Factors | |
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| Immediate or Common Causes of Medication Incidents | |
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| Root or System Causes of Medication Incidents | |
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| Summary | |
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| Reflective Questions | |
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| Prevention of Medication Incidents: Risk Management to Improve Patient Safety | |
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| Elements of Risk Management in Pharmacy | |
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| System Preventive Strategies | |
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| General Preventive Strategies for Organizations | |
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| Preventive Strategies for Pharmacies | |
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| Personal Preventive Strategies | |
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| Summary | |
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| Reflective Questions | |
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| Common Causes of Medication Incidents and Preventive Strategies | |
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| Illegible Handwriting | |
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| Look-Alike/Sound-Alike Medications | |
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| Verbal Prescriptions | |
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| Faxed Prescriptions | |
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| Missing Information | |
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| Abbreviations and Symbols | |
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| Calculation and Decimal Point Errors | |
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| Drug Device Errors | |
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| Lack of Patient Education/Understanding | |
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| Failed Communication with Patients | |
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| Summary | |
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| Reflective Questions | |
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| Underlying Root Causes and Preventive Strategies | |
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| Psychological and Human Factors | |
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| Dispensing Process | |
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| Manufacturer Issues | |
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| Reconciliation | |
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| Pharmacy Workload | |
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| Environment | |
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| Organizational Issues | |
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| Summary | |
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| Reflective Questions | |
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| Causes and Preventive Strategies in Specialty Practices | |
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| Pediatrics | |
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| Compounding | |
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| Nonprescription Medications | |
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| Immunization | |
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| Methadone Treatment | |
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| Summary | |
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| Reflective Questions | |
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| Technological Solutions Promoting Safe Medication Practices | |
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| Computerized Physician Order Entry (CPOE) | |
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| E-prescribing | |
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| Bar Code Technology | |
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| Radio Frequency Identification | |
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| Automated Dispensing | |
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| Other Technologies That Can Reduce Medication Error Rates | |
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| Limitations of Technology in Medication Error Reduction | |
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| Automation Case Study | |
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| Unit-Dose Systems | |
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| Point-of-Care Medication Administration Systems | |
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| The Impact of Facilities Design | |
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| Summary | |
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| Reflective Questions | |
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| Dealing with Medication Incidents in Pharmacy | |
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| Plan of Action for Handling a Medication Incident | |
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| Protocol for Handling a Medication Incident | |
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| Incident Reporting | |
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| Root Cause Analysis | |
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| Communication of a Medication Incident/Disclosure | |
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| Staff Issues During a Medication Incident | |
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| Summary | |
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| Reflective Questions | |
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| Instituting Safe Medication Practices in Pharmacy | |
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| Continuous Quality Improvement | |
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| Failure Mode Effects Analysis | |
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| Self-Assessment | |
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| Other Methods for Improving Patient Safety | |
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| Developing a Patient Safety Plan | |
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| Barriers to Patient Medication Safety | |
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| Summary | |
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| Reflective Questions | |
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| Organizations Involved in Patient Safety | |
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| Strategies and Tools for Prevention of Specific Types of Problems | |
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| Glossary | |
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| Index | |