| The editor of the second edition of this book has brought together some
30 experts from pharmacy, medicine, nursing and risk management to provide
up-to-date thinking about medication errors. Their contributions make
this book a comprehensive and authoritative examination of the causes
of medication errors and strategies to prevent them.
The book is divided into five parts:
(i) preparing for action
(ii) understanding
the causes of medication errors
(iii) preventing medication errors:
a shared responsibility
(iv) preventing medication errors: specific
medications, patients and conditions
(v) reducing risks and creating
a just culture of safety
The opening chapter provides a description of the role of human error
and systems failures in health care and how they can be addressed. He
discusses the “blame and train” approach to error that has
created strong pressure on individuals to cover up mistakes rather than
admit them.
There are chapters on the prevention of prescribing, dispensing and administration
errors, including errors related to drug delivery devices. A useful table
that uses failure mode and effects analysis is offered as a means of
predicting infusion pump failures.
The patient has an important role in preventing errors and health care
providers are challenged to engage patients as equal partners. Communication
is often a problem and a helpful table lists indicators of limited
literacy.
Packaging and labelling of medicines, and look-alike and sound-alike
names play an important role in patient safety. Many problems are described
in this book, along with examples of how the pharmaceutical industry
has responded to requests to improve the safety of their products. Colour
plates of some of these packs capture key information but almost all
of the plates from the first edition (1999) have been included in the
second edition.
Other chapters provide detailed discussions on specialty areas fraught
with risk such as cancer chemotherapy, paediatrics and neonatology, and
immunology and an important chapter covers “high alert” medicines
that are most frequently involved in harmful events. Reporting systems,
advice on disclosing errors to patients and families, root cause analysis,
failure mode and effects analysis, the culture of safety and clinical
bioethics are also covered in this all-embracing book.
‘Medication errors’ is extremely informative. It is thorough and
provides valuable suggestions to health care practitioners for preventing
medication errors. It is a useful reference source for pharmacists in
the UK.
Laurence A. Goldberg
(an independent consultant pharmacist and a non-executive
director of the National Patient Safety Agency)
|
The
Pharmaceutical Journal