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2 Editor: Lisa Abel Project Manager: Bridget Chambers Associate Director, Production: Johanna Harris Executive Director: Catherine Chopp Hinckley, Ph.D. Joint Commission/JCR/JCI Reviewers: Pat Adamski, Ann Jacobson, Ali Malik, Maureen Carr, Jeannell Mansur, Nanne Finis, Cynthia Leslie, Mark Pelletier, Margherita Labson, Dana McGrath, Nancy Gorman, Catherine Hinckley External Reviewer: John Gosbee Joint Commission Resources Mission The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in the United States and in the international community through the provision of education, publications, consultation, and evaluation services. Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not be construed as an endorsement of such organization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. Every attempt has been made to ensure accuracy at the time of publication; however, please note that laws, regulations, and standards are subject to change. Please also note that some of the examples in this publication are specific to the laws and regulations of the locality of the facility. The information and examples in this publication are provided with the understanding that the publisher is not engaged in providing medical, legal, or other professional advice. If any such assistance is desired, the services of a competent professional person should be sought Joint Commission Resources, Inc., Compl Kaiser Permanente, Chapter 1 Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the U.S.A Requests for permission to make copies of any part of this work should be mailed to Permissions Editor Department of Publications Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois U.S.A. permissions@jcrinc.com ISBN: Library of Congress Control Number: For more information about Joint Commission Resources, please visit For more information about Joint Commission International, please visit

3 CONTENTS Foreword vii AUTHORS: Laura E. Cima, R.N., M.B.A., N.E.A.-B.C., F.A.C.H.E., Vice President, Clinical Operations, Hackensack University Medical Center, Hackensack, New Jersey; and Sean P. Clarke, R.N., Ph.D., F.A.A.N., R.B.C. Chair in Cardiovascular Nursing Research, University of Toronto and University Health Network, Toronto, Canada Introduction 1 Chapter 1. Medication Safety: Reducing Error Through Improvement Programs 5 AUTHORS: Kaiser Permanente Northern California Suzanne Graham, R.N., Ph.D., Regional Executive Director of Patient Safety and member of The Joint Commission Patient Safety Advisory Group; Molly Clopp, R.N., M.S., M.B.A.T.M., Regional Strategic Leader, Patient Safety; Barbara Crawford, M.S., R.N., N.E.A.-B.C., Regional Vice President, Quality and Regulatory Services; Doug Bonacum, M.B.A., C.S.P., Program Office Vice President, Safety Management; Becky Richards, R.N., M.A., D.Mc., Adult Clinical Service Director, Modesto Medical Center; Celia Ryan, M.S.H.A., R.N., C.P.H.Q., Area Quality Leader, Fresno Medical Center; Nicholas Kostek, R.Ph., M.S., Regional Pharmacy Quality/Patient Safety Coordinator; and Rebecca Lalonde, R.N., M.B.A., Area Quality Leader, Santa Rosa Medical Center FOCUS: High-Alert Medications: Opioids in Home Care, Hospice, and Behavioral Health Care Settings 31 ө Chapter 2. Medication Safety: Using Technology 35 AUTHORS: Brigham and Women s Hospital, Boston Anne D. Bane, R.N., M.S.N., Director, Clinical Systems Innovations, Center for Nursing Excellence; Carol J. Luppi, R.N., B.S.N., A.L.M., Nurse Educator for Technology, Center for Nursing Excellence; Laura Mylott, Ph.D., R.N., Director of Nursing Education, Innovation, and Evidence- Based Practice, Center for Nursing Excellence; and Patrice K. Nicholas, D.N.Sc., M.P.H., R.N., A.P.R.N., B.C., F.A.A.N., Director of Global Health and Academic Partnerships, Center for Nursing Excellence, and Professor, MGH Institute of Health Professions Graduate Program in Nursing FOCUS: Technology: Benefits of Telemonitoring in Home Care 57 iii

4 The Nurse s Role in Medication Safety, Second Edition Chapter 3. Medication Reconciliation: Lessons Learned 59 AUTHORS: Our Lady of Lourdes Memorial Hospital in Binghamton, New York Caryl Ann Mannino, R.N., B.S.N., O.C.N., N.E.-B.C.; Anita Markovich, R.N., B.S.N., M.S.N., M.P.H., C.P.H.Q.; and Deborah Mican, R.N., B.S.N., M.H.A., C.N.O.R. FOCUS: Transitions in Care: Communication of Medication Information Between Health Care Settings 76 FOCUS: Patient Education: Addressing Low Health Literacy Among Home Care Aides 79 Chapter 4. Medication Errors: Risk Management 81 AUTHOR: Grena Porto, R.N., M.S., A.R.M., C.P.H.R.M., Principal, QRS Healthcare Consulting, LLC, Hockessin, Delaware, and member of The Joint Commission Patient Safety Advisory Group FOCUS: Technology: Using Telepharmacy and PIS to Reduce Risks for Medication Error in Critical Access Hospitals and Rural Hospitals 97 Chapter 5. Medication Safety: Considerations for Pediatrics 101 AUTHOR: Ronda G. Hughes, Ph.D., M.H.S., R.N., F.A.A.N., Associate Professor, Marquette University, Milwaukee FOCUS: Patient Education: Educating Parents About Their Children s Medications in Ambulatory Care 109 Chapter 6. Medication Safety: Considerations for Geriatrics 111 AUTHOR: Trish O Keefe, R.N., M.S.N., Morristown Memorial Hospital, Morristown, New Jersey FOCUS: Staff Education: Medication Technicians in Long Term Care 120 FOCUS: High-Alert Medications: Antipsychotic Medications in Long Term Care 122 iv

5 CONTENTS Chapter 7. Medication Safety: Considerations for Obstetrics 125 AUTHORS: Mary C. Brucker, C.N.M., Ph.D., F.A.C.N.M., Louise Herrington School of Nursing, Dallas; and Tekoa L. King, C.N.M., M.P.H., F.A.C.N.M., University of California, San Francisco, and Deputy Editor, Journal of Midwifery and Women s Health FOCUS: Patient Education: Educating Parents About Infant Formula Preparation 140 Chapter 8. Medication Safety: Considerations for Oncology 141 AUTHOR: Kristen Maloney, M.S.N., R.N., A.O.C.N.S., Hospital of the University of Pennsylvania, Philadelphia FOCUS: High-Alert Medications: Oral Chemotherapy Outside the Hospital Setting 150 Index 153 v

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7 FOREWORD Bill, a 58-year-old male in excellent health, is admitted to the hospital for a knee replacement. The surgery goes well, without complication, and all expect a smooth postoperative course in the acute care setting, followed by a short stay in a rehabilitation facility. Postoperatively, Bill develops bilateral deep vein thrombosis, and the surgeon and staff suspect pulmonary emboli. He is started on intraveneous (IV) heparin and does well throughout the remainder of his acute care stay. On day 4, he is transferred to a rehabilitation facility, although his preference is to go home. His wife (who is a nurse) and physicians insist on the rehabilitation facility because of the intense physical therapy that will be available to him there. He reluctantly agrees. He is transferred to the rehabilitation facility with standard admission orders for activity, diet, and so on. He has left the acute care hospital on enoxaparin sodium (low molecular weight heparin) and his usual antihypertensive medication. An order was written in the chart to discontinue the enoxaparin sodium when the INR (International Normalized Ratio) is 2. Days 1 and 2 at the rehabilitation facility are relatively uneventful, although Bill does not have his typical appetite and complains of some stomach discomfort. On day 3, he has eaten essentially nothing, refuses to get out of bed, and continues to complain of stomach discomfort. An abdominal flat plate reveals no significant findings. He wants to go home because he will feel more comfortable there, and safer. However, it is a holiday and most pharmacies are closed. He needs his prescription for pain medication (for the knee replacement) filled, so he and his wife decide to wait until morning and she will pick him up. At 4:00 A.M. the following morning, his wife receives a phone call from the nurse at the rehabilitation facility: We are taking your husband to the nearest hospital. He is having difficulty breathing and his blood pressure is dropping. His wife meets him in the emergency room at the hospital. It s obvious from his appearance that he is critically ill. Initial laboratory tests reveal an INR of 4 and hemoglobin of 5.7. Diagnosis: massive retroperitoneal bleed, secondary to enoxaparin sodium overdose. He is admitted to intensive care, where he stays for four days, during which time he is transfused with 11 units of blood and 8 units of fresh frozen plasma. He is seen by multiple physician specialists because the hemorrhaging has caused his organs to shift. In addition, he undergoes surgery for a Greenfield filter because he can no longer take anticoagulants. He is finally transferred to a medical/surgical unit. After two days, he is discharged home. Thankfully, he has no residual physical effects. The cause of this emergency: The order to discontinue the enoxaparin sodium when the INR was 2 was missed; that is, the order was transcribed, but the enoxaparin sodium was never discontinued when the INR was 2, as the physician ordered. The psychological fallout of this episode on both the patient and his family was incalculable. Bill and his family are now skeptical and mistrusting of the health care system. Bill claims he will never go back to a hospital again because they [the staff] almost killed him. He is correct. His wife and one of his daughters, who is a nurse like her mother, gained a firsthand appreciation of medication errors and their impact from the client s side. The financial impact of this error: more than $100,000 in unexpected medical bills. ө vii

8 The Nurse s Role in Medication Safety, Second Edition The Issue of Errors The error described previously hits rather close to home. The patient who experienced it is a family member of one of the editors of this book. The need for safer medication management practices became crystal clear to all associated with this error. Bill was fortunate. According to the physicians who cared for him after this incident, had he not been in such good physical condition before these events, he never would have survived this error. This case is an example of just one of the many types of medication errors that occur daily in health care settings, resulting in thousands of injuries and deaths and millions of dollars in additional expenditures. For payers, this problem represents a huge generator of unnecessary and wasteful spending of scarce health care dollars. To the organizations where errors occur, errors represent a public relations problem, lost revenue, and even legal exposure problems. For health care providers, this statistic and the underlying problem raise deep concern and discomfort. And to consumers of health care the most important stakeholders here the problem and its magnitude are absolutely frightening. It s no wonder that the Centers for Medicare & Medicaid Services (CMS) has focused its attention on patient safety issues. The total cost for medical errors was estimated at $19.5 billion in ; and as of 2006, it was estimated that medication errors alone could result in as much as $3.5 billion in additional medical expenses in the United States. This figure is admittedly rough, and does not include, for instance, the lost wages and productivity of individuals requiring additional medical intervention. 2 In its role as a leading health care payer, the CMS is at the forefront of efforts to advance patient safety by using incentives related to payment of hospitals to drive better practices. As of October 2008, hospitals are no longer reimbursed by the CMS for additional costs connected with the treatment of a number of conditions not present at the time of a patient s admission those that were acquired during the patient s hospital stay and were likely preventable. These events include foreign objects retained after surgery, air embolism, blood incompatibility, Stage III and IV pressure ulcers, falls or trauma resulting in serious injury, and catheter-associated vascular and urinary tract infections. Expected to join this list soon are surgical site infections following specific elective procedures, including certain orthopedic and bariatric surgeries; certain manifestations of poor glycemic control; and deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures. 3 Interestingly, the issue of medication errors has yet to be addressed by the CMS, but given the frequency of these errors and expenses connected with them, similar measures excluding reimbursement are likely on the horizon. The press releases around the often-cited 1999 Institute of Medicine (IOM) report To Err Is Human emphasized an estimate of the death toll from medical errors in U.S. hospitals as high as nearly 100,000 per year. Not surprisingly, this report created a media frenzy and led to patient safety issues skyrocketing to the top of agendas for health care providers, payers, and consumers. Since the publication of that report, many safety experts have expressed skepticism that much progress has been made to improve patient safety in hospitals. 4 More recently, an IOM report synthesizing research and expert opinion settled on an estimate of one medication error per patient per day of hospitalization. 5 Today, despite all of the steps taken to avoid medication errors, patients and families still enter the U.S. health care system fearful that there will be a mistake in their care, particularly related to the medications they receive, or worse that they will become a statistic or a news story. Medication safety is a concern globally as well, with hospital medical, nursing, and pharmacy leaders viii

9 FOREWORD around the world working in cooperation and bringing in other disciplines to advance safer medication practices. More recently an IOM report synthesizing research and expert opinion settled on an estimate of one medication error per patient per day of hospitalization. 5 The Probability of Errors Why do medication errors still plague health care systems around the world? James Reason, a safety expert, has pointed out that basic probability theory tells us that processes involving complex chains of tasks (such as safe delivery of drug therapy to hospitalized patients) are doomed to fail on a regular basis unless errors are trimmed down to the very smallest levels in each of the component processes. 6 A task containing 40 elements, each of which is completed with 95% accuracy, will be totally successful only 12% of the time. Given enough steps, any process will break down in time. Even when each step is completed with 99.99% accuracy, a process with 100 steps will run into at least one problem at least 1 in 100 times. Errors in the Medication Management Processes Every step in a medication management system plays a role in getting the right medication to the right patient at the right time by the correct route. Although some minor details may be altered by newer technologies, the essence of the process has not remained constant. Process experts have identified at least nine distinct steps in medication management,* many of which involve more than one health discipline, and at each step there is potential for error: 1. Procurement 2. Storage 3. Prescribing 4. Repackaging 5. Transcription 6. Preparation 7. Dispensing 8. Administration 9. Monitoring The safety of patients receiving drug therapy is contingent on diligence and interdisciplinary collaboration within each step of a medication management system. Gosbee and Gosbee, in their book Using Human Factors Engineering to Improve Patient Safety, recommend that health care leadership adapt the human factors engineering (HFE) philosophy to the issue of patient safety, a move that is needed to overcome the blame and shame attitude. 7 Rather than look at individuals who are involved in an adverse event, HFE looks at the system failures behind the event to develop long-term, lasting resolution. A poorly designed system, according to Laura Lin Gosbee, is one that does not match the needs of the human or task or does not take into account human limitations. 8(pp. 4 5) She adds that among the human characteristics that have limitations are perception, memory, and anthropometrics. Human capabilities and limitations include such concerns as physical limitations, posture and movement, fatigue and sleep deprivation, environmental factors, and cognitive limitations. 8 All of these phenomena must be considered in designing effective and safe systems. Causes of Errors Patient safety experts have concluded that medication errors happen for a number of reasons, but the most common causes include the following 9 : DEFINED: Medication Errors, ADEs, and ADRs Medication errors are not the same as adverse drug events (ADEs) or adverse drug reactions (ADRs). The following definitions clarify the distinctions among these terms 10 : An ADE is harm caused by a drug (adverse drug reactions and overdoses) or from use of the drug (dose reductions and discontinuations of drug therapy). An ADR is a harmful response to a drug taken normally at normal doses. Medication errors are mistakes that occur during prescribing, transcribing, preparing, administering, or monitoring of a drug. Medication errors do not necessarily result in an ADE. * The Joint Commission also identifies distinct parts of a medication management system, each of which has standards defined to meet accreditation requirements. ix

10 The Nurse s Role in Medication Safety, Second Edition Poor communication, such as incomplete patient information, illegible handwriting, or miscommunication of drug orders Ambiguities in product names, dosing units, or medical abbreviations Lack of appropriate labeling Environmental factors, such as lighting, heat, noise, and interruptions Patient misuse because of poor understanding of the directions for use of the medication The Nurse s Role And Responsibility The process of preventing errors and addressing the reasons they occur requires vigilance as well as consistent and systematic doublechecking throughout the medication management process. As noted above, medication management must be driven by the objective of patient safety. For nurses, this objective must be pursued in collaboration with other disciplines, specifically physicians and other prescribers, as well as pharmacists and nursing colleagues. Even with increased standardization of drug ordering, computerized delivery systems, and bar coding, nurses must feel comfortable raising concerns and asking for clarifications about orders that do not make sense to them. Although members of any discipline can make mistakes in the chain of steps in the medication management process, nurses who are at the sharp end of the process have a unique role in preventing medication errors. They are usually the last individuals who stand between the medication and the patient. They must be conversant with an ever-increasing array of medications, some of which are highly toxic, such as chemotherapeutic agents. They must be acutely aware of all aspects of drug safety: safe dosages, safe and appropriate diluents, and medication side effects and signs of overdosing, as well as look-alike/sound-alike medications. And they must be willing and able to educate patients and their families about medication regimens. The responsibility carried by nurses is indeed weighty, and the nurse s role in medication safety is a challenging one never to be taken lightly. The Second Edition This second edition of the The Nurse s Role in Medication Safety updates and expands on the concepts of the first edition and provides an international perspective on medication safety practices as well. In this edition, readers can consider anew the ever-growing availability of technology and its implications for the nurse s role in medication safety. They can get fresh insight into risk management concerns with medication administration and subsequent errors. The needs of the special populations in geriatrics, pediatrics, and oncology, as well as the obstetric dyad of mother and fetus are highlighted. Woven throughout the discussions are best practices and error-avoidance strategies in medication management, all offering new perspectives on familiar concepts. It is our hope that this book will prove helpful to nurse leaders and nursing staff, as well as their colleagues, who are such critical links in the chain of medication management. Our goal is to help you, your colleagues, and your institutions achieve safer medication management systems and to reduce the number of stories like Bill s. Laura E. Cima, R.N., M.B.A., N.E.A.-B.C., F.A.C.H.E., Vice President, Clinical Operations, Hackensack University Medical Center, Hackensack, New Jersey Sean P. Clarke, R.N., Ph.D., F.A.A.N., R.B.C. Chair in Cardiovascular Nursing Research, University of Toronto and University Health Network, Toronto, Canada References 1. Hobson K.: Study puts cost of medical errors at $19.5 billion. Wall Street Journal Health x

11 FOREWORD Blog, Aug. 9, health/2010/08/09/ (accessed May 30, 2011). 2. National Academy of Sciences, National Academy of Engineering, Institute of Medicine, National Research Council: News from the National Academies. Jul. 20, www8.nationalacademies.org/onpinews/ newsitem.aspx?recordid=11623 (accessed May 18, 2011). 3. Managed Care First Report: CMS the Latest to Deny Payment of Hospital-Acquired Conditions show_story.php?newsid=6697 (accessed May 21, 2011). 4. HealthGrades, Inc.: HealthGrades Quality Study: Patient Safety in American Hospitals. Denver: Health Grades, Aspden P., et al. (eds.), Committee on Identifying and Preventing Medication Errors, Institute of Medicine: Preventing Medication Errors, Quality Chasm Series. Washington, DC: National Academies Press, Reason J.: Managing the Risks of Organizational Accidents. Aldershot, UK: Ashgate Publishing, Gosbee J.W., Gosbee L.L. (eds.): Using Human Factors Engineering to Improve Patient Safety: Problem Solving on the Front Line, Second ed. Oakbrook Terrace, IL: Joint Commission Resources, Gosbee L.L.: Theory and general principles. In Gosbee J.W., Gosbee L.L. (eds): Using Human Factors Engineering to Improve Patient Safety: Problem Solving on the Front Line, Second ed. Oakbrook Terrace, IL: Joint Commission Resources, 2010, pp U.S. Food and Drug Administration: Medication Errors. drugs/drugsafety/medicationerrors/ default.htm (accessed Aug. 23, 2011). 10. Veterans Affairs Center for Medication Safety and Veterans Health Administration Pharmacy Benefits Management Strategic Healthcare Group and the Medical Advisory Panel: Adverse Drug Events, Adverse Drug Reactions and Medication Errors: Frequently Asked Questions. Nov Adverse%20Drug%20Reaction.pdf (accessed Jul. 12, 2011). xi

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13 INTRODUCTION Nurses are the last discipline in the chain of medication administration. This places them in a pivotal position in medication management and error avoidance. Often, the individual responsible for the medication error becomes the focus of the event, usually with a re-education plan or a disciplinary process as the intervention. However, this practice just diverts leadership s attention from the true culprit of the error, the systems and procedures established for medication management. Because they are in this key role of administering medications, nurses have many opportunities to assess, analyze, and provide feedback regarding those systems in order to prevent medication errors and improve processes. One such approach is filing incident reports or unusual occurrence reports that can provide useful trending information on medication errors or close calls ( almost errors ) and drive needed changes in medication management processes, policies, and procedures. However, historically, nurses completing incident reports have feared punishment and retribution by managers and peers. Still others have questioned the real impact on care and whether, particularly in the face of overwork, the time invested in completing reports is worthwhile. Nurses, as patient advocates, can do much to make health care institutions safer for patients. Nursing research, education, and the implementation of best practices will help this cause. Strong collaborative relationships with physicians and other providers, pharmacists, nursing colleagues, and leadership are a must in the quest for patient safety. In addition, it is the responsibility of nurses as practitioners to share best practices with their colleagues (wherever they may practice) to help create a safer health care environment. Purpose of This Book The purpose of the second edition of The Nurse s Role in Medication Safety is to enhance the concepts of medication safety practices presented in the first edition. The authors and nurse researchers have provided multiple evidence-based practices on a number of topics related to medication management processes and procedures, all aimed at assisting nurses to improve systems in the organizations in which they practice in order to create safer environments. In addition, this book provides an international perspective on this important patient care issue. In brief, the book offers advice from nurse experts and nurse researchers on the role of nurses as it pertains to the following topics: The importance of implementing medication safety improvement programs that reflect an understanding of human factors and promote a safe, just culture The technology available to enhance safety in medication management and recommendations for nurses in the use of technology The lessons learned from medication reconciliation processes and tips to improve the processes Risk management concerns and recommendations for investigating the cause of medication errors Medication safety issues in selected clinical populations: pediatrics, geriatrics, obstetrics, and oncology ө 1

14 The Nurse s Role in Medication Safety, Second Edition Medication safety issues in selected clinical settings: long term care, home care, ambulatory and office-based surgery, behavioral health care, and critical access hospitals Overview of Contents Chapter 1. Medication Safety: Reducing Error Through Improvement Programs This chapter, contributed by authors from Kaiser Permante Northern California, discusses the many issues involved in implementing successful medication safety programs. The High-Alert Medication Program (HAMP), a multidisciplinary approach to medication administration developed by a team at Kaiser Permanente, is reviewed and offered as a process to avoid drug errors. Human and environmental conditions that contribute to medication errors are discussed, including the impact of disruptive behavior and interruptions to the medication nurse. The role of technology and the value of an ongoing education program to address errors are also addressed, as is ensuring a safe and just culture for error reporting. The result of the multipronged approach at Kaiser has led to positive culture changes and a safer medication administration process in which nurses actively participate. Chapter 2. Medication Safety: Using Technology In Chapter 2, nurse leaders at Brigham and Women s Hospital in Boston discuss the role of technology in creating safer medication administration processes, including the use of computerized provider order entry and protocol-based checklists in concert with performance improvement techniques. Each step of medication management is addressed from the standpoint of available technology. The importance of nurse involvement in the selection and design of new technologies and education about those technologies is also emphasized. Chapter 3. Medication Reconciliation: Lessons Learned The lessons learned from medication reconciliation processes are the topic of this chapter. Recommendations from several agencies concerned with patient safety, such as The Joint Commission, the World Health Organization, and the Agency for Healthcare Research and Quality, are drawn upon in discussions about accurate medication reconciliation to promote patient safety. Strategies for error avoidance through appropriate medication reconciliation procedures are emphasized as critical throughout the continuum of care. Approaches to medication safety by the leadership at Our Lady of Lourdes Hospital in Binghamton, New York, are presented as best practices. Chapter 4. Medication Errors: Risk Management Chapter 4 addresses why medication errors continue to happen despite the steps that have been taken to prevent them. Incorrect approaches and the reasons why these approaches are incorrect are discussed. The author discusses the effective risk management approach, identifying each component as well as tools that may be used in each. Appropriate investigative processes to determine the reason(s) for error are outlined as well, providing nurses with a comprehensive approach to understanding why errors occur in their organization. An eight-step process for implementing risk-reduction strategies provides a guide for nursing leaders to begin analyzing processes to create a safer patient environment. Chapter 5. Medication Safety: Considerations for Pediatrics Pediatrics, one of the most vulnerable of populations, is addressed in terms of appropriate ordering of medications and calculations of doses. Factors influencing medication safety and incidence of errors (calculation, skill of practitioner, and organizational issues) are presented in this chapter, with strategies to 2

15 INTRODUCTION prevent errors in this population offered to nurses practicing in this environment. Chapter 6. Medication Safety: Considerations for Geriatrics The growing geriatric population and the issues of side effects of medications and polypharmacy are addressed. The Beers Criteria are discussed as a best practice to ensure safe geriatric medication management. Nursing strategies related to medication management for the geriatric population are offered. Chapter 7. Medication Safety: Considerations for Obstetrics This chapter addresses medication issues in obstetrics. Also emphasized is the transmission of medication through breast milk, the impact of medication administered at different stages of pregnancy prenatal, intrapartum, and postpartum and potential threats to the mother and fetus. These discussions offer the nurse an overview of medication safety in this population. Chapter 8. Medication Safety: Considerations for Oncology The high-alert class of antineoplastic medications are a mainstay of treatment for this patient group. Safer and best practices are discussed that address look-alike/sound-alike medications, nursing education, and the involvement of patients and families in medication safety. Focus Features Although medication errors or adverse drug events (ADEs) are more researched and publicized in the hospital setting, they can occur just as easily and commonly in settings outside the hospital, such as in ambulatory care and stand-alone surgical facilities or surgery centers, behavioral health care, home care, and long term care organizations. They can also occur in rural and critical access hospitals, which, although hospitals, may have special needs for medication management that more urban or larger hospitals and hospital systems may not have. Nurses in these settings need to be just as vigilant in preventing errors as providers in the hospital setting. Following each chapter is a Focus feature that highlights a medication safety issue in one or more of these settings as it relates to high-alert medications, technology, transitions in care, or patient and staff education. The information in these brief features may, in addition, help support nurses across the continuum of care to reduce the risks of medication errors. Terms Used in This Book This book addresses both general and specific health care settings. For general discussions, the term patient will be used to discuss the care recipient. In cases in which a specific setting is discussed, the care recipient will be addressed with terminology appropriate for the setting. For example, patient will be used for hospital, ambulatory care, and home care settings; individual will be used for behavioral health care settings; and resident will be used for long term care settings. The term health care in this book refers to all types of care, treatment, or services provided within the spectrum of the health care field, including physical, medical, and behavioral health care. When Joint Commission standards that apply to multiple program settings are quoted in this book, the term organization will represent any specific program setting (for example, hospital) in the original program standards text. Acknowledgements Publications of this nature are the result of the important contributions of many individuals. Joint Commission Resources (JCR) is grateful to all of those who contributed to the success of this book. We are particularly grateful to this edition s content editors: Laura E. Cima, R.N., M.B.A., N.E.A.-B.C., F.A.C.H.E., Vice President of Clinical Operations, Hackensack University Medical Center, Hackensack, 3

16 The Nurse s Role in Medication Safety, Second Edition New Jersey; and Sean P. Clarke, R.N., Ph.D., F.A.A.N., R.B.C. Chair in Cardiovascular Nursing Research, University of Toronto and University Health Network, Toronto, Canada. We also greatly appreciate all the authors who shared their experiences in developing strategies to help nurses improve medication safety. And many thanks go to Meghan Pillow, a nurse and freelance writer/editor, for her work on the Focus features that appear between the chapters. JCR is also grateful to the multiple reviewers and content experts for their feedback to ensure that the overall content is accurate and relevant to the various health care settings. Those reviewers are listed on the copyright page. Special thanks goes to Jeannell Mansur, Joint Commission Practice Leader in Medication Safety, for her thorough reviews, which improved the book throughout its development. 4