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Table of Contents
Contributors .................................................................................................................. v
Foreword ....................................................................................................................... ix
Darryl S. Rich
Acknowledgements ....................................................................................................... xi
SECTION I : THE IMPORTANCE OF MEDICATION SAFETY
Chapter 1. Medication-Use Safety as a Problem in Public Policy ............................. 1
Henri R. Manasse, Jr., and Kasey K. Thompson
Chapter 2. The Role of the Leader in Advancing Patient Safety ............................... 17
Vicki Crane
Chapter 3. A Business Case for Patient Safety? ........................................................... 33
Joseph K. Bonnarens and Lee C. Vermeulen
Chapter 4. Blueprint for a Culture of Safety ................................................................ 41
Joanne E. Turnbull
Chapter 5. What to Focus on First—Prioritizing Safety-Improvement Initiatives .... 57
Michael D. Sanborn
SECTION II: THE MEDICATION-SAFETY TEAM
Chapter 6. Thinking about Accidents and Systems .................................................... 73
Richard I. Cook and Michael F. O’Connor
Chapter 7. Building an Effective Medication-Safety Team ......................................... 89
Sondra May
Chapter 8. The Practice-Change System Applied to Medication Safety .................. 107
Christine M. Nimmo and Ross W. Holland
Chapter 9. Federal Government, State Government, and Private-Sector Roles in
Improving Medication Safety ............................................................................... 121
Jerry Phillips
SECTION III: BUILDING A SAFE MEDICATION-USE SYSTEM
Chapter 10. Applying Best Practices and Scientific Evidence to
Improving Patient Safety ....................................................................................... 141
Timothy S. Lesar
Chapter 11. The Role of Effective Communication in Health Care
Delivery Systems ................................................................................................... 163
C. J. Biddle
Chapter 12. Designing an Internal Reporting and Learning System ......................... 171
David N. Gragg
Chapter 13. The Safe Use of Technology in Hospitals and Health Systems ............ 185
Kevin Marvin
Chapter 14. Application of Human Factors Engineering in Process and
Equipment Design ................................................................................................. 201
Laura Lin Gosbee and Mary E. Burkhardt
Chapter 15. Safe Supply-Chain Management ............................................................. 227
Marsha K. Millonig and Bruce R. Siecker
Chapter 16. Root-Cause Analysis and Healthcare Failure Mode and Effects
Analysis: Two Proactive Harm-Prevention Strategies .......................................... 237
John F. Mitchell
Chapter 17. Drug Information Resources and Medication Safety ............................. 253
Gerald K. McEvoy
Chapter 18. Patient Safety in Clinical Trials ............................................................... 275
William R. Hendee
Chapter 19. Poison Centers: A Key Component of the Patient-Safety System....... 291
Daniel J. Cobaugh
SECTION IV: MEASURING MEDICATION SAFETY
Chapter 20. Medication-Safety Self-Assessments ....................................................... 299
Bruce M. Gordon
Chapter 21. Characteristics of High-Reliability Organizations ................................. 319
Henri R. Manasse, Jr., and Kasey K. Thompson
Chapter 22. International Perspectives on Patient Safety........................................... 327
David Cousins
Chapter 23. The Science of Patient-Safety Research ................................................. 351
Richard J. Faris
Chapter 24. The Role of the Patient and Family in Preventing
Medication Errors .................................................................................................. 367
Roxanne J. Goeltz
Index .............................................................................................................................. 375
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