RT Book, Section A1 Weber, Robert J. A2 DiPiro, Joseph T. A2 Yee, Gary C. A2 Posey, L. Michael A2 Haines, Stuart T. A2 Nolin, Thomas D. A2 Ellingrod, Vicki SR Print(0) ID 1182422070 T1 Medication Safety Principles and Practices T2 Pharmacotherapy: A Pathophysiologic Approach, 11e YR 2020 FD 2020 PB McGraw-Hill Education PP New York, NY SN 9781260116816 LK accesspharmacy.mhmedical.com/content.aspx?aid=1182422070 RD 2024/03/29 AB KEY CONCEPTS Medication errors (MEs) are defined as any mistake at any stage of the medication-use process; adverse drug events (ADEs) are the result of an injury as a result of an ME. All MEs can be prevented, while ADEs can be categorized as preventable and potential. MEs occur at an alarmingly high rate, with some ADEs having fatal outcomes for patients. MEs can occur at any step of the medication-use process: selection and procurement, storage, ordering and transcribing, preparing and dispensing, administration, or monitoring. Determining the actual and potential root causes of MEs helps to correct future errors in the medication-use system. Quality improvement methods that prevent MEs and thereby minimize ADEs include identifying the ME and/or ADE, understanding the reasons for the ME and/or ADE, designing and implementing changes to prevent an ADE or ME, and checking the outcome of that change. Healthcare organizations have implemented various measures to reduce the incidence of MEs and ADEs, such as computerized physician order entry (CPOE), automated drug distribution systems, bar-code scanning, and “smart” infusion pumps with decision support and where information is passed in a bidirectional manner between the pump and the patient’s electronic medical record (EMR). Medication reconciliation or comparing a patient’s current medication orders to all of the medications that the patient had been taking before any care transition (hospital admission, transfer, or discharge) is a vital process in preventing MEs and ADEs. Promoting a Just Culture of medication safety cultivates trust in the workplace that makes personnel feel comfortable sharing safety information (eg, unsafe situations) and assuming personal responsibility and accountability for complying with safe medication practices.