Book contents
- Medication Safety during Anesthesia and the Perioperative Period
- Medication Safety during Anesthesia and the Perioperative Period
- Copyright page
- Dedication
- The Snow Vaporizer, Mark II
- Contents
- Foreword
- Acknowledgments
- 1 Introduction to Medication Safety in Anesthesia and the Perioperative Period
- 2 Failures in Medication Safety during Anesthesia and the Perioperative Period
- 3 Failures in Medication Safety in the Intensive Care Unit and Ward
- 4 Impact of Medication Errors on the Patient and Family
- 5 Consequences for the Practitioner
- 6 Why Failures Occur in the Safe Management of Medications
- 7 Errors in the Context of the Perioperative Administration of Medications
- 8 Violations and Medication Safety
- 9 Interventions to Improve Medication Safety
- 10 Medication Safety in Special Contexts
- 11 Legal and Regulatory Responses to Avoidable Adverse Medication Events, Part I: General Principles
- 12 Legal and Regulatory Responses to Avoidable Adverse Medication Events, Part II: Practical Examples
- 13 Barriers to Improving Medication Safety
- 14 Conclusions
- Index
- References
6 - Why Failures Occur in the Safe Management of Medications
Published online by Cambridge University Press: 09 April 2021
Book contents
- Medication Safety during Anesthesia and the Perioperative Period
- Medication Safety during Anesthesia and the Perioperative Period
- Copyright page
- Dedication
- The Snow Vaporizer, Mark II
- Contents
- Foreword
- Acknowledgments
- 1 Introduction to Medication Safety in Anesthesia and the Perioperative Period
- 2 Failures in Medication Safety during Anesthesia and the Perioperative Period
- 3 Failures in Medication Safety in the Intensive Care Unit and Ward
- 4 Impact of Medication Errors on the Patient and Family
- 5 Consequences for the Practitioner
- 6 Why Failures Occur in the Safe Management of Medications
- 7 Errors in the Context of the Perioperative Administration of Medications
- 8 Violations and Medication Safety
- 9 Interventions to Improve Medication Safety
- 10 Medication Safety in Special Contexts
- 11 Legal and Regulatory Responses to Avoidable Adverse Medication Events, Part I: General Principles
- 12 Legal and Regulatory Responses to Avoidable Adverse Medication Events, Part II: Practical Examples
- 13 Barriers to Improving Medication Safety
- 14 Conclusions
- Index
- References
Summary
The process of medication management in anesthesia is both complicated (numerous steps) and complex, in that it requires continual adaptation to a continually changing environment. In addition, medication safety depends on systemic factors, some of which involve processes far from the clinical interface. The system in which medications are managed is complex, if only because humans are a key part of this system. The processes of human cognition are particularly complex, and include knowledge, evidence, information, wisdom and expertise. These processes are explored in some detail, including a discussion of short term and long-term memory. Each practitioner responds to an internally developed mental model of the current situation, which may differ considerable from that of other team members. An understanding of complexity and human cognition may often provide an explanation for failure in healthcare: such an understanding provides a foundation for our overall pursuit of medication safety.
Keywords
- Type
- Chapter
- Information
- Publisher: Cambridge University PressPrint publication year: 2021
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