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Matthew Grissinger, RPh, FISMP, FASCP, is the Director of Error Reporting Programs at the Institute for Safe Medication Practices (ISMP). Prior to joining ISMP, he served as a home care and long-term care pharmacy surveyor for the Joint Commission (TJC). Mr. Grissinger has published numerous articles in the pharmacy literature, including regular columns in P & T and the Patient Safety Advisory (PSA). He serves on the National Quality Form (NQF) Common Formats Expert Panel, the Faculty Advisory Board for the Pharmacy Learning Network (PLN), and the Publications Advisory Board for Davis’ Drug Guide for Nurses. He is an adjunct assistant professor for Temple University School of Pharmacy and clinical assistant professor for the University of the Sciences in Philadelphia. Mr. Grissinger received a BS in Pharmacy from the Philadelphia College of Pharmacy and Science and is a Fellow of the ISMP as well as the American Society of Consultant Pharmacists.

Michael Cohen, RPh, MS, ScD, is President of the ISMP. He is editor of the textbook Medication Errors and serves as coeditor of the ISMP Medication Safety Alert!, publications that reach over 2 million health professionals and consumers in the United States and in over 30 countries. Dr. Cohen is a member of the Sentinel Event Advisory Group for TJC and recently served as a member on the Committee on Identifying and Preventing Medication Errors for the Institute of Medicine (IOM). In 2005, he was recognized as a MacArthur Fellow by the John D. and Catherine T. MacArthur Foundation. In 2008, Dr. Cohen was honored by the NQF and TJC with the John M. Eisenberg Patient Safety and Quality Award in recognition of his lifelong professional commitment to promoting safe medication use and a safe medication delivery system.



After completing this chapter, readers should be able to:

  1. Discuss the role of the pharmacist in preventing medication errors.

  2. Define latent and active failures and the role each plays when a medication error occurs. Define the types of medication errors that can occur during the ordering and dispensing process.

  3. List some commonly used drugs that can result in medication error-related deaths.

  4. Describe what changes are needed at the risk management level to better address medication safety issues, including the use of failure mode and effects analysis to reduce the potential for errors.

  5. Identify specific problems in our approach to error prevention and what needs to be changed to ensure patient safety.

  6. Describe a variety of methods that can be used to identify risk and provide meaningful data on the relative safety of their facility’s medication use process.

  7. Select high-leverage error reduction strategies based on sound safety principles.


This scenario is based on a true story that demonstrates the multiple breakdowns that can occur during the medication use process.

An infant was born ...

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