Foreword.

Preface.

Systems Analysis and Redesign: The Foundation of

Medical Error Prevention.

Research on Errors in Dispensing and Medication Administration.

Health Care Providers’ Experiences with Making Fatal Medication Errors.

Causes of Medication Errors.

Root Cause Analysis of Medication Errors.

The Role of Drug Names in Medication Errors.

The Role of Drug Packaging and Labeling in Medication Errors.

Error-Prone Abbreviations and Dose Expressions.

Preventing Prescribing Errors.

Preventing Dispensing Errors.

Preventing Drug Administration Errors.

Preventing Medication Errors Related to Drug Delivery Devices.

The Patient’s Role in Preventing MedicationErrors.

High-Alert Medications: Safeguarding Against Errors.

Using Technology to Prevent Medication Errors.

Preventing Medication Errors in Cancer Chemotherapy.

Preventing Medication Errors in Pediatric Patients.

Preventing Medication Errors with Immunologic Drugs.

Medication Error Reporting Systems.

Disclosing Medication Errors to Patients and Families.

Health Care Failure Mode and Effects Analysis.

The Clinical Bioethics of Safe Medication Practices.

Managing Medication Risk through a Just Culture of Safety.

Index.

Color Plates

Michael R. Cohen, BPharm, MS, ScD, President, Institute for Safe Medication Practices, Huntingdon Valley, Pennsylvania.