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From page 447... ... Index A patient self-administration, 83�84 in pediatric care, 114�115, 395�396 Accountability prevention of errors in, 80�81, 83, 250� performance measurement for, 330 251 state reporting systems for, 92 procedure, 79�80 Accreditation research needs, 21 curricula recommendations, 344 responsibility, 79 recommendations for, 22, 329, 335 Adverse drug events (ADEs) See also Joint Commission on costs, 130�133, 202 Accreditation of Healthcare definition, 3, 4�5, 36, 37, 38, 311�312 Organizations detection methods, 237�239, 241�245 Acetaminophen, 31, 83, 115 incidence. Read the entire page →
From page 448... ... 448 INDEX data standardization role, 324 Anesthesia Patient Safety Foundation, 296 recommendations for, 12, 19, 20, 21, Anesthesiology, 296�297, 301 192, 274, 275, 288, 310�311 Anti-anxiety drugs, 421�422 Alerts and alert systems Antibiotic medications, 71, 84, 125, 126, current technology, 287 128, 373, 375 false alerts and overrides, 20, 251�252, Anticoagulant therapy, 88�89, 125, 249, 293�294 270, 313�314, 382 intelligent prompting, 295�297 Aspirin, 31, 270 scope of, 287 Associated in Process Improvement, 157 severity ranking, 293, 294 Atrial fibrillation, 125, 127, 382 standardization, 288, 293�295 Automated dispensing systems See also Computerized drug event effectiveness, 251, 418 monitors; Computerized provider implementation, 334 order entry linkages among automated and Allergic reactions computerized systems, 252, 287 clinical decision support to prevent, 246 overrides of warnings, 252 prescribing errors, 71 purpose, 30, 77�78 preventable ADEs in hospitals, 119 Ambulatory care costs of medication errors in, 5�6, 131, B 132 electronic prescribing in, 14, 253 Bacterial infection prophylaxis, 125, 126. See also Antibiotic medications incidence of medication errors, 108, 112�114, 124, 314, 384�392, 396� Bar coding, 413 397 alert systems, 287, 293�294 error prevention efficacy, 6, 413 information resources in, 206 medical record keeping in, 387�388 Food and Drug Administration rules, medication administration in, 429 297�298 future prospects, 298�299 medication error detection in, 244 medication therapy management in, linkages among automated and 429�430 computerized systems, 252, 287 in nursing home medication use, 252�253 opportunities for patient consultation, 173�174 purpose, 14, 30, 81, 250�251 overutilization of medications in, 128 regulatory requirements, 280 research needs, 318, 319 patient monitoring in, 323, 387 pediatric, 396�397 standardization, 288, 291, 297�299 preventable ADEs in, 5, 124 use interface, 300�301 Best Pharmaceuticals Act for Children, 268 prevention research, 319�320 research needs, 21, 314, 323 Biologic Licensing Application, 59 strategies for reducing errors in, 428�430 Biologic products, 35 Blood and blood products, 35 underutilization of medications in, 127� 128 Brand name drugs, 277, 278 American Academy of Pediatrics, 29, 434 Bridges to Excellence, 331 Bronchitis, 128 American Hospital Association, 160 American Medical Association, 410 American Medical Informatics Association, C 343�344 American Nurses Association, 410 Cancer treatment, 164 American Society of Health-System Caregivers Pharmacists, 29, 429 error risk, 116, 186 American Society of Hospital Pharmacists, incidence of pediatric medication errors, 410 314�315 Read the entire page →
From page 449... ... INDEX 449 right to refuse treatment for dependents, Clear RxTM, 198 191 Clinical decision-support systems, 26, 30, training and support for, 186 85, 122 Case management, pharmaceutical, 432� current state, 232 433 effectiveness, 6, 414�417 Causes of medication errors and adverse for electronic prescribing, 247�248 events future prospects, 232 areas of evaluation for improving care, implementation, 253�255 33 intelligent prompting, 295�297 in care transitions, 255 overrides of warnings, 251�252, 293 communication-related, 17�18, 182� rationale, 232 183, 234, 274, 275 recommendations for, 16, 26, 228 in computerized order entry, 74 standardization, 335 in drug administration process, 81�83 user interface, 300 overutilization, 125, 128�129, 274�275, See also Alerts and alert systems 384 Clinical trials in pharmaceutical industry, 266�267 considerations in prescribing, 71 in pharmacy practice, 75, 76, 77, 78�79 disclosure of results, 57�58, 271�274 in prescribing process, 71�74 informed consent rules, 159 research needs, 2, 317 new drug development process, 55�56 risk/benefit information, 17 registration site, 271, 272 scope of, 37, 43, 51, 70 regulatory oversight, 63 systemic context, 45, 184�187 shortcomings of current health system, transcription of prescription, 75�76, 17, 56�57, 267�271 378, 394 Clinical unit, 222�228 underutilization, 125, 126�128, 234� ClinicalTrials.gov, 271�272 235, 382�384 Cochrane Collaboration, 13 user interface-related, 299�301 Cognitive processing See also Dosage errors; Nonadherence drug labeling and, 19, 274 Center for Health and Health Care in medication information leaflet design Schools, 434 considerations, 195�196, 274 Centers for Disease Control and Prevention patient with impairment, 185 adverse event reporting system, 93�94 research needs, 318 National Center for Health Marketing, technology interface design, 20, 288, 206�207 299�302 Centers for Medicare and Medicaid Services Colds, 128 comparative performance reports, 331 Comorbodity drug formularies, 66 adverse event risk, 86 electronic prescribing rules, 336 research needs, 17, 269 information dissemination role, 207 Complementary and alternative medications recommendations for, 12, 21, 22, 192� consumer health attitudes and beliefs, 193, 310�311, 312, 329, 333�334 189�190 role of, 33 definition, 35 Certification Commission on Health drug interactions, 116 Information Technology, 254�255 error prevention strategies, 435�438 Chart review, 241�242 information access for consumers and Chemical name, 275 providers, 182 Chemotherapy error incidence, 113 medication error rate, 108, 116, 316 Chronic Care Model, 157�158 patient self-prescribing, 74�75 Chronic coronary disease, 125 research needs, 21, 316 Claims data, 341 utilization, 31, 32, 189 Read the entire page →
From page 450... ... 450 INDEX Compliance. See Nonadherence Continuity of Care Record, 322 Computerized drug event monitors, 30, 85� Coronary artery disease, 128 86, 242�243, 251 Cost of care Computerized point-of-care reference computerized order entry, 253 information, 13, 229�232 considerations in treatment planning, 70 Computerized prescribing. Read the entire page →
From page 451... ... INDEX 451 Depression treatment, 125, 127, 382, 422 medication-use system, 66�70, 89, 90 Diabetes patient self-monitoring, 88 number of pharmaceutical agents, 51 Dietary Supplement Health and Education opportunities for intervention, 53, 67 Act. See Complementary and principles for safe practice in, 50�51, 53 alternative medications stages of drug development and delivery, Dietary supplements. Read the entire page →
From page 452... ... 452 INDEX shortcomings of current system, 11�12, drug labeling and packaging oversight, 179, 181�183 19, 60�62, 193�194, 195, 196, 274� See also Information resources 275, 279�280 Electronic ADE detection, 242�243 drug manufacturing and distribution Electronic health records oversight, 63 certification, 254�255 drug name selection process, 278, 280 data standards, 289 drug safety activities, 32�33, 51�53 error risk, 372�373 error reporting systems, 89 implementation trends, 334�335, 2044 information dissemination role, 29, 207, purpose, 203�204, 222, 253 312 standardization, 336 in new drug development, 51, 55, 56, Electronic prescribing, 30 58�60 decision support rules, 247�248 recommendations for, 12, 19, 21, 192� implementation challenges, 13�14 193, 274�275, 310�311 linkages among automated and Formularies computerized systems, 252, 287 characteristics of current system, 66 in nursing homes, 14, 252 cost of drugs and, 187 in outpatient care, 253 definition, 66, 129 oversight and implementation, 33 effects on safety, 129 potential for error, 248 effects on utilization, 129 rationale, 13, 30, 246, 247 Free drug samples, 18, 19, 65�66, 179, 275, recommendations, 16, 228�229, 246 285�287, 387 regulatory restrictions, 247 standardization, 335 state regulation, 336 G Emergency departments cost of admissions related to prior Generic drugs ADEs, 130�131 free samples, 285�287 naming conventions, 275�277, 278 medication error rates, 114�115, 397 overutilization of antibiotics in, 128 Geriatric medicine pediatric, 114�115, 397 adherence, physical impairment and, 184�185 Errors of omission, 5, 26, 28, 36, 69, 108 clinical knowledge base, 268�269 cost of care, 187 F drug information access and utilization, 181 Failure modes and effects analysis, 278 health system trends, 32 Fatigue, provider, 31, 419 medication regulation in nursing homes, Federal government 419�423 adverse event reporting and surveillance multidisciplinary team approach to care, system, 92�94 250 information technology role, 334 patient monitoring in, 86 patient rights guarantees, 159�160 psychotropic medications, 398�399, recommendations for, 11�13 419�423 role in preventing medication errors, 2 risk of medication error, 17, 57, 86, See also Regulation and oversight; 313�314, 398�399 specific agency or department See also Nursing homes Fever treatment, 116 Food and Drug Administration adverse event reporting system, 59, 92 H bar coding rules, 297�298 clinical trials oversight, 159 Hand-offs. See Transition between care settings Read the entire page →
From page 453... ... INDEX 453 Health care providers incidence of medication errors and access to information, 181, 231�232 ADEs, 1�2, 4, 5, 108�111, 118�122, actions to improve medication safety, 8� 125, 313, 323, 367�376 10 opportunities for patient consultation, attitudinal barriers to provider�patient 174�176 partnership, 187�189 performance assessment, 341 disclosure of errors to patients, 160� psychiatric, 399 162, 177�179 research needs, 318�319 drug industry marketing to, 65 strategies for preventing medication effective clinical units, 222�228 errors and ADEs, 6, 318�319, 409� handwriting, 74 419 information needs, 229�231 underutilization of medications in, 125, integration of complementary and 126�127 alternative medications, 189�190 Human factors design interpersonal skills, 171�173, 178 drug labeling, 19, 274 medication reconciliation, 14�15, 168� medication information leaflets, 195� 169 196, 274 multidisciplinary teams, 248�250 significance of, 50 opportunities for patient consultation, technology interface, 20, 288, 299�302 173�176 Hypertension management, 127, 268 patient education role, 171�173 performance measurement, 330�331 public opinion, 151�152, 153 I recommendations for, 22, 248, 329 reporting behaviors, 152 Ibuprofen, 31 Incidence of medication errors and ADEs scope of, 38 workforce development, 342�344 adherence-related errors, 86, 114, 179, See also Education and training of 390�391 in ambulatory care, 108, 112�114, 124, medical personnel; Nursing; Pharmacy practice; Prescribing 314, 384�392, 396�397 practice; Provider�patient partnership areas of evaluation for improving care, 33 to prevent medication errors; Psychiatric care in chronic illness, 86 Health maintenance organization drug in complementary and alternative medication use, 108, 116, 316 formularies, 66 Health Plan Employer Data and current estimates, 1�2, 28, 116�118 Information Set, 341 data sources, 105�108 definition of medication error and, 311 Hearing impairment, 185 Heart failure, 125 detection methods, 4 Hemodialysis, 113 in drug administration, 4, 28, 110�112, 114�115, 369�371, 376�378, 395� Heparin, 270 Home care, 85, 389�390, 433. See also 396 Ambulatory care; Transition between in emergency care, 114�115, 397 errors of omission, 28, 108, 373�376 care settings Hormone replacement therapy, 267�268 in geriatric medicine, 86, 398�399 Hospital Incident Reporting Ontology, 340 in home care pharmacy, 389�390 in hospitals, 1�2, 4, 5, 108�111, 118� Hospitals computerized order entry in, 253�254 122, 125, 313, 323, 367�376 costs of ADEs in, 130�132 in mail-order pharmacy, 388�389 measurement methodologies, 109 drug repackaging, 77 in medication-use process, 109 Read the entire page →
From page 454... ... 454 INDEX in nursing homes, 108, 111�112, 122� consumer access, 205 123, 313�314, 376�384 consumer behavior, 75 in over-the-counter drug use, 108, 116, consumer demand, 165�166 315 current publishing system, 271�272 overutilization errors, 125, 128�129, current technologies, 286�287 384 data standards, 20, 287, 288 patient monitoring errors, 86, 371, 373, design considerations, 195�196 378 drug labeling and packaging, 17�19, 183 in pediatric care, 4, 108, 114�115, 314� drug risk/benefit information, 17 315, 393�398 goals, 205 in pharmacy practice, 28, 113�114, 367, government role, 334 369, 376, 388�389, 394�395 integration of technologies, 287 in prescribing, 71, 109�110, 112�113, international comparison studies, 323 114�115, 314, 367�369, 373�376, Internet, 11�12, 198�200 385�387, 393�394 interoperable medication data, 233�236 preventable adverse drug events, 5, 118� medication information leaflets, 11�12, 125, 109�110 183, 192, 193�196 in primary care, 86 for medication reconciliation, 14�15, in psychiatric care settings, 108, 115� 168�169 116, 315, 398�400 minimum functionality standards for research needs, 2, 3, 21, 118, 313�316, technology, 22, 329, 334�336 400 in new drug development process, 54 in school health care, 112, 391 patient safety educational materials for in self care, 114, 390�391 providers, 343 underutilization errors, 125, 126�128, for patient self-prescribing, 74�75 382�384 for pharmacists, 76, 79, 234 in use of over-the-counter drugs, 108, pharmacy database, 76, 287 116, 315 point-of-care reference information, 13, variation across facilities, 4, 117 229�232 Industry, pharmaceutical, 38 for preventing drug administration communication of drug information, 17� errors, 83 18, 183, 266�267 proposal for national registry, 272�274 drug formularies, 66 provider access systems, 231�232 free sample distribution, 18, 19, 65�66, provider needs, 229�231 179, 275, 284�286, 387 publication bias, 272 manufacturing oversight, 63 recommendations for improving, 12�13, potential sources of medication error in, 16, 20, 192�193, 228�229, 274�275, 51, 266 287�288 product recalls, 51 research to enhance consumer use and recommendations for, 18�19, 20, 274� comprehension, 312 275, 287�288 reward for investment in, 331 role in improving medication safety, shortcomings of current system, 11�12, 150, 266�267 17�18, 181�183, 267, 271�272 stages of drug development and standardization of health information distribution, 50, 51 technology, 19�20, 31, 289�293 See also Marketing and distribution of structure and scope of national drugs; Research and development, medication safety system, 205�207 new drug technology interface design, 299�302 Informatics, 50 technology training for providers, 343� Information resources 344, 427 clinical data, 267�271 telephone helpline, 12, 192, 200�203 Read the entire page →
From page 455... ... INDEX 455 See also Alerts and alert systems; L Educational interventions; Surveillance and reporting Labeling and packaging Informed consent, 159 black box warnings, 61 Institute for Healthcare Improvement, 25� consumer use and understanding, 75 26, 157, 168�169 container labels, 196�198 Institute for Safe Medication Practice, 29, drug interaction data, 87 89, 91, 240, 245, 341, 410 drug samples, 387 Insurance over-the-counter medications, 61, 438 barriers to provider�patient partnership, recommendations for, 18�19, 274�275 184 regulatory oversight, 60�62, 193�194, cost of care as cause of nonadherence, 195, 196, 278�279 186�187 shortcomings of current system, 17�18, drug formularies, 66, 129, 187 194, 196�198, 275, 276�277, 278� Intensive care units 280 incidence of drug administration errors, as source of medication error, 45, 77, 371 79, 267, 275 medication error rates in, 110 strategies for improving, 198, 280, 281� patient monitoring in, 85 282 International comparison, 323 See also Unit-of-use packaging Internet Leapfrog Group, 297, 331, 335 clinical trial data, 271, 272 Legal environment consumer health behaviors, 198�199 barriers to reporting, 339 National Library of Medicine programs, Internet pharmacies, 64 199�200 patient rights, 7 online pharmacies, 64, 199 right to refuse treatment, 191 quality of health information on, 11�12, state-mandated adverse event reporting, 199 89, 91�92 recommendations for, 12, 192 Lehman, Betsy, 27 Intravenous medication Libraries, 206 administration errors, 110, 370, 371 Lidocaine hydrochloride, 279 causes of error in, 299�300 Long-term care error prevention technologies, 251 cost of medication errors in, 5, 132 See also Smart intravenous pumps patient monitoring in, 85 preventable ADEs in, 5, 112, 125 See also Nursing homes J Joint Commission on Accreditation of M Healthcare Organizations, 25�26 data standardization activities, 324, 340 Mail order pharmacies National Patient Safety Goals, 31, 222, error incidence, 388�389 225�226, 337 legal status, 64 patient rights oversight, 159, 160 operations, 64 reconciliation standards, 169 research needs, 314 Sentinel Event Policy, 29�30, 91, 410 Managed care organization drug formularies, 129 Marketing and distribution of drugs K distribution system, 63�64 free drug samples, 18�19, 19, 65�66, Katrinahealth.org, 233�234 179, 275, 284�286 Read the entire page →
From page 456... ... 456 INDEX industry spending on promotion, 64, 65 computerized drug event monitors, 30, marketing effects, 65 85�86, 242�243, 251 in overall drug system, 51 errors in nursing homes, 112, 378 promotional techniques, 64�65 errors in pediatric care, 396 regulatory review, 62, 63 goals, 2, 15, 84, 86�87 shortcomings of current system, 66 intelligent prompting systems, 295�297 Medical rounds, 6, 413, 417 methods and technologies, 84, 85 Medicare observation of medication adverse event risk, 86 administration, 243�244 claims data, 341 patient self-monitoring, 87�89 electronic prescribing rules, 336 pharmacist role, 85�86 medication therapy management in, preventable ADEs related to, 371, 373 333�334 provider knowledge for, 87 outpatient preventable adverse drug recommendations for, 16, 228 events, 5 research needs, 322�323 prescription drug benefit, 32, 33 responsibility, 84 provider performance assessment, 341 scope, 84�85 See also Centers for Medicare and See also Alerts and alert systems; Medicaid Services Computerized drug event monitors; Medicare Modernization Act, 335 Surveillance and reporting Medicare Prescription Drug Improvement Monoamine oxidase inhibitors, 88 and Modernization Act, 176 Mortality, 25, 28 Medication administration record, 81 Multidisciplinary team approach to care, Medication errors 248�250 case examples, 27, 43�49, 152�153 Myocardial infarction, 125, 126, 127, 382 cause for concern, 1, 26�28 costs. Read the entire page →
From page 457... ... INDEX 457 Near miss, 311�312 O New Drug Application, 59, 270�271 Nonadherence Official title of medication, 277 causes of, 179, 184 Off-label use, 71, 268 cognitive impairment and, 185 Omnibus Budget Reconciliation Act, 419� consumer health attitudes and beliefs 420, 421�422, 423 and, 189 Organizational psychology, 50 cost of care and, 186�187 Orphan drugs, 77 costs of, 6 Osteoporosis, 125, 127, 382 definition, 179 Outpatient care. See Ambulatory care drug side effects as cause of, 186 Overdose incidence, 86, 114, 179, 390�391 case example, 43�45 interventions to prevent, 434 in self-administration of drugs, 83 physical impairment as cause of, 184� See also Dosage errors 185 Over-the-counter medications provider�consumer communication and, consumer role in improving safety, 8 182 definition, 35 Nursing disease� and drug�drug interactions, adequate staffing, 30 116, 315�316 case example of medication error, dosing errors, 83 43�45 incidence of medication errors, 108, drug administration procedure, 79�80 116, 315 drug effect monitoring responsibility, 84 label warnings, 61, 438 education programs for nurses, 342 patient self-prescribing, 74�75 educational interventions in nursing regulatory review, 60 homes, 423, 424�425 research needs, 21, 315�316 home health care, 390 scope of, 51 interpersonal skill training, 172 self-monitoring when using, 87�88 observation of medication strategies for error prevention, 435�438 administration, 243�244 utilization, 31 strategies for improving medication safety, 80, 222, 225 workload issues, 82 P Nursing homes Pain management, 125, 127, 382�384 automated and computerized Patient-centered care medication-use technologies for, 14, attitudinal barriers to, 188�189 252�253 characteristics of organizational culture costs of medication errors in, 131 based on, 188 drug administration in, 376�378 conceptual model, 157�158 incidence of medication errors and consumer empowerment in, 158�162, ADEs, 108, 111�112, 122�123, 313� 163�164 314, 376�384 consumer expectations, 153 overutilization errors, 384 essential elements, 153�155, 156 research needs, 319 goals for, 143�150 strategies for preventing medication provider responsibilities, 166 errors and ADEs, 6, 319, 419�427 quality of communications in, 155, 172� underutilization of medications in, 127, 173 382�384 rationale, 155�157 workforce education, 423�425 self-management support in, 157�158 See also Long-term care See also Provider�patient partnership to prevent medication errors Read the entire page →
From page 458... ... 458 INDEX Patient rights Pharmacy practice clinical significance, 7, 158 alert systems, 287 current standards, 7�8, 159�160 ambulatory care, 388�389 to disclosure of adverse events, 7, 160� bar-coding technology in, 250�251 162, 177�179 case management service, 432�433 informed consent, 159 communication of drug information, 17� pharmacy consultation, 176 18, 182 provider responsibility, 8�10 continuing education, 337, 338 recommendations, 11, 162 database systems, 76, 287 right to refuse treatment, 191 drug distribution system, 63�64 in treatment planning, 159 drug industry marketing to, 64�65 Patient Safety: Achieving a New Standard effective technologies, 14 for Care, 26 electronic prescribing and, 247 Patient Safety and Quality Improvement free samples, 18, 19, 65�66, 179, 275, Act, 91, 244�245, 339, 340 284�286, 387 Patient Safety Event Taxonomy, 324, 340 in hospitals, 119�120, 367, 369 Pediatric medicine incidence of medication errors in, 28, caregiver error in fever treatment, 116 113�114, 119�120, 367, 369, 376, clinical knowledge base, 268 388�389, 394�395 emergency care, 397 information kiosks, 205�206 immunizations, 396�397 information leaflets, 11�12, 183, 192, incidence of medication error, 4, 108, 193�196 114�115, 314�315, 393�398 information resources, 76, 79, 234 medication error risk, 17 Internet and mail-order pharmacies, 64, patient monitoring, 396 388�389 pharmacy practice, 77, 114 medical school training, 342 prescribing practice, 393�394 medication therapy management, 333� research needs, 320�321 334, 426 strategies for medication error multidisciplinary team approach to care, prevention, 320�321, 435 248 surrogate decision-making, 191 in nursing homes, 376 People's Medical Society, 29 observation of medication Performance measurement, 341 administration, 244 pathways to quality improvement, 330� overrides of automated warnings, 251� 331 252, 293 pay-for-performance systems, 331�333 participation in medical rounds, 6, 417 Personal health record patient education in, 6, 75, 78, 176 consumer self-management and, 312� patient monitoring, 85�86 313 pediatric, 394�395 current state, 203�204 pediatric medicine, 77, 114 essential components, 204�205 point-of-care reference information, 13, interoperable medication data, 233�236 229�232 minimum data set, 12, 193, 312 prescription audits, 244�245 rationale, 203�204 prescription refills, 320, 337 recommendations for, 12, 16, 193, 228 process components, 35, 76�79 reconciliation in care transitions, 14�15, recommendations for, 16, 228 168�169 recommendations for oversight, 22, 329 types of, 204 research needs, 320 vendor responsibilities, 12 risk/benefit analysis, 17 See also Electronic health records sources of error in, 75, 76, 77, 78�79 Pharmacy benefits manager, 64 state pharmacy boards, 336�338 Read the entire page →
From page 459... ... INDEX 459 strategies for improving medication provider profiling and feedback, 425� safety, 6, 30�31, 76�78, 222, 224� 426 225, 417�418, 431�433 recommendations for improving transcription of prescriptions, 75�76, mediation safety, 16, 228�229, 246 378, 394 research needs, 320 working environment, 431�432 responsibility, 70 workload, 176 strategies for improving medication See also Automated dispensing systems; safety, 222, 223, 318, 428�429 Computerized provider order entry; transcription of prescription, 75�76 Prescribing practice types of prescribing errors, 71�74 Pictograms, 195�196 underutilization, 125, 126�128 Placebo studies, 57 See also Computerized provider order Point-of-care reference information, 13, entry; Pharmacy practice 229�232 Preventable adverse drug events Poison control centers, 202�203 in ambulatory care, 124 Postmarket surveillance of new drugs, 34, costs, 5, 130�133 59�60 definition, 37, 38 Potassium chloride, 279 in hospitals, 118�122, 125 Prescribing practice incidence, 5, 109�110, 118�125 in ambulatory care, 314, 385�387, 428� in long-term care, 125 429 measurement methodology, 119�120, assessment of patient medication history, 123 74 in nursing homes, 122�123, 313�314 bar-coding technology in, 250�251 Prevention of medication errors best practices, 70 in ambulatory care, 319�320, 428�430 clinical decision making, 71 areas of evaluation for improving, 33�34 educational intervention in prescription in care transitions, 8, 14�15, 321�322, writing, 428�429 427�428 electronic. See Electronic prescribing clinical decision-support system errors of omission, 373�376 effectiveness, 6, 414�417 in home care settings, 389�390 computerized order entry effectiveness, in hospitals, 119�120, 367�369 6, 414�417 inappropriate use, 71 consumer actions, 163�166 incidence of medication errors in, 71, cost/benefit studies, 317�318 109�110, 112�113, 114�115, 119� criteria for evaluating strategic 120, 314, 367�369, 373�376, 385� approaches, 34 387, 393�394 in drug administration, 80�81, 83, 250� intelligent prompting systems, 295�297 251 interoperable medication data, 233�236 drug effect monitoring, 84�89, 251 knowledge base for, 71, 181, 230 drug formulary effectiveness, 129 length of provider�patient visits and, drug name�related efforts, 278 184 effective clinical unit characteristics, off-label use, 71 222�228 oral orders, 74, 76, 113, 247, 318, 388 effective use of technologies for, 14, 16, overrides of automated warnings, 251, 250�255 293 evaluation of current efforts, 106 overutilization, 125, 128�129 financial incentives, 22, 329 patient involvement, 70 future prospects, 317 patient self-prescribing, 74�75 in home care setting, 433 in pediatric care, 320, 393�394 in hospitals, 6, 318�319, 409�419 prescriber handwriting, 74 Read the entire page →
From page 460... ... 460 INDEX interoperable medication data for, 233� consumer empowerment for, 158�162, 236 163�164 lessons from other industries, 323�324 consumer role, 8, 163�166 in medication-use system, 67 current state, 152�153 multidisciplinary team approach for, goals, 6�7 248�250 knowledge needs for, 181�183 in nursing homes, 6, 319, 419�427 length of provider�patient visits, 184 obstacles to, 10 patient rights, 7�8 opportunities for intervention in drug provider role, 8�10, 166�179 system, 53 rationale, 2 patient monitoring, 85�87 recommendations for, 11, 162�163 patient self-monitoring for, 87�88 strategies for strengthening, 151, 153� in pediatric care, 320�321, 435 154 in pharmacy practice, 6, 30�31, 76�78, Psychiatric care 222, 224�225, 417�418, 431�433 drug formularies, 129 in prescribing, 71, 222, 223, 318, 428� geriatric medicine, 398�399 429 medication errors in, 108, 115�116, provider education and training for, 313�314, 315, 398�400 342�344 medication regulation in nursing homes, in psychiatric care, 321, 435 419�423 recent efforts, 25�26, 29�31 prevention strategies, 321, 435 reconciliation for, 14�15, 168�169 research needs, 21, 269, 321 regulatory system recommendations, 22, stigma and discrimination in, 190�191 329 Public opinion, 151�152, 153 research needs, 2, 20�21, 317�322 risk/benefit information for, 17 role of state pharmacy boards, 336�338 Q in self-administration of drugs, 83�84, Quality improvement pathways, 330�333 435�438 in self-care, 433�434 setting-specific strategies, 221�222 R stakeholder motivations, 67 stakeholders, 38�39, 50, 150 Race/ethnicity, consumer health attitudes strategic approaches, 6, 10, 28�29, 150 and beliefs, 189 systemic change for, 143�145, 221 Reconciliation See also Preventable adverse drug events; barriers to implementation, 169 Provider�patient partnership to in care transitions, 255 prevent medication errors characteristics, 168 Program of All-Inclusive Care for the effectiveness, 168, 428 Elderly, 250 electronic data management in, 15, 169 Proton pump inhibitors, 129 goals, 168 Provider�patient partnership to prevent implementation, 169, 255, 428 medication errors, 153�154 process, 14, 168�169 attitudinal barriers to, 187�191 rationale, 14 barriers to, 179�191 use of interoperable information systems characteristics of reformed health care in, 236 system, 143�149 Record keeping communication skills for, 172�173, 182, consumer medication list, 2, 8, 164�165, 183 234 concept of patient-centered care in, 153� Continuity of Care Record, 322 158 electronic, 14 Read the entire page →
From page 461... ... INDEX 461 errors in ambulatory care settings, 387� pediatric care, 320�321 388 prevention strategies, 21, 317�322 medication administration record, 8, 81 recommendations for, 21, 310�311 recommendations, 11, 16, 162, 228 technology implementation, 319 See also Electronic health records; Research and development, new drug Personal health record Biologic Licensing Application, 59 Regional Health Information Organizations, clinical trials, 55�57 322 conflicts of interest in, 57 Regulation and oversight current state, 55, 56�57, 58 clinical trials, 63, 159 disclosure of results, 57�58, 271�274 drug labeling and packaging, 19, 60�62, effectiveness review, 59 193�194, 195, 196, 274�275, 279� expansion to new indications, 270 280 fast track approval, 55, 59 drug manufacturing and distribution, generics, 60 63�64, 65�66 goals, 54�55 drug marketing activities, 62, 64�65 information management in, 54 electronic prescribing, 33, 247, 336 manufacturing controls, 63 guiding principles, 329�330 marketing materials review, 62 information technology standards, 334� New Drug Application, 59 336 over-the-counter products, 60 medication therapy management, 333� in overall drug system, 51 334 placebo studies, 57 new drug review, 58�59 postmarket studies, 34, 59�60, 270, 272 patient rights, 159, 160 product labeling, 60�62 pharmacy practice, 22, 329 regulatory oversight, 58�62 for process improvement, 330�333 risk assessment, 58 psychotropic drug use in nursing homes, safety oversight, 51�53 419�423 scope of activities in, 54 recommendations, 22, 329 shortcomings of current system, 58, 62, See also Food and Drug Administration; 270�271 Joint Commission on Accreditation stages, 55 of Healthcare Organizations; Respiratory tract infections, 128�129 Surveillance and reporting Rewarding Results, 332 Religious beliefs, 191 Rofecoxib. See COX-2 inhibitors Renal dysfunction, 17, 269 Reporting. Read the entire page →
From page 462... ... 462 INDEX patient-centered Chronic Care Model, Substance use/abuse, 190�191 157�158 Surrogate decision-making, 176�177, 186, patient education for, 171, 427 191 physical impairments to, 185�186 Surveillance and reporting self-monitoring, 87�89 administrative databases, 341 self-prescribing, 74�75 chart review for, 241�242 strategies for preventing medication computerized drug event monitors, 30, errors in, 419, 433�434 85�86, 242�243, 251 trading/sharing of drugs among confidentiality in, 91 consumers, 190, 391 cost/benefit analysis of systems for, 324 See also Consumer role in preventing current practice in disclosing errors, 152 medication errors; Nonadherence; current programs, 89 Over-the-counter medications data analysis, 245 Side effects, 186 drug utilization review in ambulatory Smart intravenous pumps care, 430 alert systems, 293�294 effectiveness, 91 application, 85, 251 federal systems, 59, 92�94 effectiveness, 6, 418 feedback for reporters, 341�342 medication errors related to, 299�300 goals, 15, 237, 245 research needs, 318, 319 institutional systems, 89, 91 Special populations interoperable medication data, 234, 236 research needs, 17 measurement of medication error See also Geriatric medicine; Pediatric incidence and, 109 medicine medication administration errors, 243� St. John's Wort, 116 244 Standardization methods, 15, 237�239 alert systems, 288, 293�295 obstacles to, 91, 339 bar codes, 288, 290, 297�299 practice-related errors, 340�341 data standards, 20, 287, 288, 324 prescription audits, 244�245 drug labeling, 280 rationale, 15, 89, 338�339 drug names and abbreviations, 18, 19, recommendations for, 16, 22, 228�229, 44, 274, 289�293 236, 329 health information technology, 19�20, self-reports for, 237 31, 334�336 significance of, 237 interoperable medication data, 233�234 standardization of requirements, 89, medication error terminology, 311�312, 339�340 324 state-mandated, 89, 91�92 medication information leaflets, 12, 192, strategies for improving current systems, 195, 200 239�240 patient rights, 7�8, 159�160 strategies to encourage reporting, 339 pediatric dosages, 320 voluntary systems, 15, 29�30, 89, 92, reporting system, 89, 339�340 239, 240�241 State governments See also Monitoring, patient electronic prescribing laws, 336 informed consent rules, 159 mandatory reporting systems, 89, 91�92 T medication error reduction actions, 334 patient rights guarantees, 159�160 Take with Care, 29 pharmacy boards, 336�338 TargetTM stores, 198 Tavistock Group, 160 recommendations for, 22, 329 Statins, 129, 315�316 Telephone helpline effectiveness, 200�201 Read the entire page →
From page 463... ... INDEX 463 establishing national system of, 202�203 current practice, 77�78, 80, 282�283 future challenges, 202 definition, 18, 282 providers, 201 forms of, 282 recommendations for, 12, 192 future prospects, 283�284 services, 201�202 rationale, 18, 283, 284 Telephone pharmacy orders. See Prescribing recommendations, 19, 274�275 practice, oral orders U.S. Read the entire page →

From page 447...

... Index A patient self-administration, 83�84 in pediatric care, 114�115, 395�396 Accountability prevention of errors in, 80�81, 83, 250� performance measurement for, 330 251 state reporting systems for, 92 procedure, 79�80 Accreditation research needs, 21 curricula recommendations, 344 responsibility, 79 recommendations for, 22, 329, 335 Adverse drug events (ADEs) See also Joint Commission on costs, 130�133, 202 Accreditation of Healthcare definition, 3, 4�5, 36, 37, 38, 311�312 Organizations detection methods, 237�239, 241�245 Acetaminophen, 31, 83, 115 incidence.

Index Pages 447-464

Index
Pages 447-464