Strategies for safety with tools for implementation. Medication Errors, 2nd Ed. Michael R. Cohen,...
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JOURNAL OF HEALTHCARE RISK MANAGEMENT • VOLUME 27, NUMBER 2 15 Book Review Strategies for safety with tools for implementation Medication Errors, 2nd Ed. Michael R. Cohen, editor Publisher: American Pharmacists Association; 679 pages: $79.95 Comprehensive and insightful, Medication Errors incorpo- rates multiple strategies to prevent medication errors, combined with concise and practical tools for medical providers to include in their medication safety programs. This reference combines research on causes of medication errors with poignant personal case examples. The text drills down to the essence of medication errors, starting with the first three chapters that focus on medication error analysis, research and provider experiences with fatal medication errors. Chapter 2 focuses on research in error dispensation with studies involving inpatient and outpatient and community pharmacies. Six methods for error detection are discussed: 1) anonymous self-reports (questionnaires), 2) incident reports, 3) critical incident techniques (in-depth analysis of a large number of individual errors), 4) chart reviews, 5) computer-assisted monitoring and 6) direct observation. Using automated systems The book promotes error prevention through automated medication systems, which feature comprehensiveness (control over the medication system, starting with order entry and continuing through medication administration), focus on accommodating dosage forms (e.g., pediatric oral liquids that are often involved in errors), unit dose dispensing for nurses to avoid additional handling before administration, signals telling when a doses are due, labeling of medications before arrival at patient care unit, and bar codes or radio frequency tags for precise identification. In Chapter 4, risk managers will appreciate the steps given for conducting root cause analyses (RCAs). This chapter includes a step-by-step chart to assist in preparing a comprehensive RCA, with action items and measures. Chapters 9, 10, 11, 12 and 13 focus on the elements of prescription or physician order errors, highlighting drug names that look or sound alike, selecting the proper dosage and order writing practices. There are practical recommendations for safe design and use of preprinted orders and order sets which warn against dangerous abbreviations (as specified by the Joint Commission and Institute for Safe Medication Practices). Additional tools in these chapters include safety recom- mendations for verbal orders, steps for ensuring accurate dispensing and principles of designing medication labels for patient-specific inpatient use. Chapter 11 provides information for nursing medication administration, which will be invaluable to nursing education efforts. The text includes areas where nursing is vulnerable regarding transcribing medication orders and drug admin- istration, with tools to prevent those errors. Again, there are compelling personal examples of medication errors with serious – sometimes fatal – consequences. Chapters 14, 15, 16, 17 and 18 cover specific patient populations especially vulnerable to medication errors such as chemotherapy, pediatric and neonatal patients as well as patients with immunologic drug prescriptions. Table 14-1 summarizes actions for safe use of high-alert medications and some error reduction strategies. Facing narcotics incidents Narcotics incidents are among the most frequent of all serious incidents reported, according to Medication Errors. One reason cited for errors with these drugs is that injectable narcotics are usually kept in nursing areas as floor stock items. Doses are often identified, prepared and administered by the same nurse with no redundant safety checks.
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Transcript of Strategies for safety with tools for implementation. Medication Errors, 2nd Ed. Michael R. Cohen,...
JOURNAL OF HEALTHCARE RISK MANAGEMENT • VOLUME 27, NUMBER 2 15
Book Review
Strategies for safety with tools for implementation
Medication Errors, 2nd Ed.
Michael R. Cohen, editor
Publisher: American Pharmacists Association; 679 pages: $79.95
Comprehensive and insightful, Medication Errors incorpo-rates multiple strategies to prevent medication errors,combined with concise and practical tools for medicalproviders to include in their medication safety programs.
This reference combines research on causes of medicationerrors with poignant personal case examples. The textdrills down to the essence of medication errors, startingwith the first three chapters that focus on medicationerror analysis, research and provider experiences with fatalmedication errors.
Chapter 2 focuses on research in error dispensation withstudies involving inpatient and outpatient and communitypharmacies. Six methods for error detection are discussed:1) anonymous self-reports (questionnaires), 2) incidentreports, 3) critical incident techniques (in-depth analysisof a large number of individual errors), 4) chart reviews,5) computer-assisted monitoring and 6) direct observation.
Using automated systems
The book promotes error prevention through automatedmedication systems, which feature comprehensiveness(control over the medication system, starting with orderentry and continuing through medication administration),focus on accommodating dosage forms (e.g., pediatric oralliquids that are often involved in errors), unit dose dispensingfor nurses to avoid additional handling before administration,signals telling when a doses are due, labeling of medicationsbefore arrival at patient care unit, and bar codes or radiofrequency tags for precise identification.
In Chapter 4, risk managers will appreciate the steps givenfor conducting root cause analyses (RCAs). This chapterincludes a step-by-step chart to assist in preparing a comprehensive RCA, with action items and measures.
Chapters 9, 10, 11, 12 and 13 focus on the elements ofprescription or physician order errors, highlighting drugnames that look or sound alike, selecting the properdosage and order writing practices. There are practical recommendations for safe design and use of preprintedorders and order sets which warn against dangerous abbreviations (as specified by the Joint Commission and Institute for Safe Medication Practices).
Additional tools in these chapters include safety recom-mendations for verbal orders, steps for ensuring accuratedispensing and principles of designing medication labelsfor patient-specific inpatient use.
Chapter 11 provides information for nursing medicationadministration, which will be invaluable to nursing educationefforts. The text includes areas where nursing is vulnerableregarding transcribing medication orders and drug admin-istration, with tools to prevent those errors. Again, thereare compelling personal examples of medication errorswith serious – sometimes fatal – consequences.
Chapters 14, 15, 16, 17 and 18 cover specific patientpopulations especially vulnerable to medication errorssuch as chemotherapy, pediatric and neonatal patients as well as patients with immunologic drug prescriptions.Table 14-1 summarizes actions for safe use of high-alertmedications and some error reduction strategies.
Facing narcotics incidents
Narcotics incidents are among the most frequent of all seriousincidents reported, according to Medication Errors. Onereason cited for errors with these drugs is that injectablenarcotics are usually kept in nursing areas as floor stockitems. Doses are often identified, prepared and administeredby the same nurse with no redundant safety checks.
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16 JOURNAL OF HEALTHCARE RISK MANAGEMENT • VOLUME 27, NUMBER 2
Medication Errors cites the common mix-up of hydromor-phone and morphine due to look-alike product namesand the misconception that hydromorphone is the genericname for morphine (in fact, hydromorphone is approximatelyfive times as potent as morphine).
Recommended improvements regarding narcotics includelimiting oral liquid opioids to conventional concentrations,dispensing concentrated oral morphine solutions only whenordered for a specific patient, separating morphine andhydromorphone in drug storage areas, considering deletingparegoric and opium tincture from hospital formulary,not storing opium tincture on patient care units and dispensing opium tincture or individual patients in asmall dropper bottle or unit dose package.
Chapter 15 describes tools to incorporate in a medicationmanagement process where technology plays a role. Thischapter focuses on pharmacy computer systems and programsthat can improve detection and correction of prescriptionerrors and interactions. Table 15-4 states specific roles for computer linkage to assist pharmacist and preventmedication errors.
This chapter also includes examples (with strengths andweaknesses) of automated dispensing cabinets (ADC),computerized prescriber order entries (CPOE), bar codingand smart pumps.
The latter part of Medication Errors focuses on reducing riskand creating a just culture of safety within organizations.
Chapter 20 provides guidance for risk managers andphysicians regarding medication error disclosure. The authorssuggest the following criteria for determining whether anevent should be disclosed: 1) the outcome would not beincluded in a reasonable informed consent process, wouldnot be expected during usual treatment, or both; and 2) it is not possible to exclude error, human or system, fromthe cause of the outcome.
Who could benefit from this book?
Risk managers, patient safety officers, physicians, pharmacistsand nurse educators all should find Medication Errors tobe a practical and useful reference regarding complex issuesin medication administration and safety. It comes completewith clearly stated, well documented analyses and multipleprovider tools that can be implemented in numerous patientcare settings.
Reviewed by Wendy Jones, RN, LNCC, MSN, assistantrisk manager at the University of California-San DiegoMedical Center.
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