Joint Commision Resources, Foreword by Jeannell Mansur. Oakbrook Terrace, Illinois: Joint Commission Resources; 2008. $75. ISBN 978-1-59940-209-3. 124 pp.

Healthcare's approach to making improvements in patient safety was dramatically changed by the Institute of Medicine's report in 2000. This easy-to-navigate book on high-alert medications by the Joint Commission Resources offers a succinct, very practical, and yet comprehensive guide to improving medication management within the overall umbrella of our learning about how to decrease errors and minimize harm. Inclusion of this book as a resource for any healthcare entity involved in medication management processes is highly recommended.

The number of preventable deaths from medication errors in the United States continues to be a startling statistic despite increased attention and efforts toward improvement. The purpose of the book is to guide healthcare organizations in reducing the likelihood of patient harm associated with use of high-alert medications. This book is appropriate for anyone involved in any aspect of medication management processes, including selection and procurement, storage, ordering and transcribing, preparation and dispensing, administering, and monitoring. The book is very well organized, starting with a focus on fundamental essentials, including our new understanding of system contribution to error and system redesign for improvement, as well as the importance of developing a safety culture that supports these efforts. Included in the book is very practical information with specific examples, case studies, and tools, as well as cited Web and print resources for additional information for addressing each aspect of improvement needed in the medication management processes. Clinical nurse specialists and clinical nurse specialist students will find this book a current state-of-the art guide to problem identification and improvement of medication management processes directed at all 3 spheres of practice with concise chapters devoted to background and rationale, regulatory issues, identification of implications for specific high-alert medications and processes, redesign approaches and tools, examples of specific approaches used by healthcare organizations, and implications for education of patients and their caregivers.