Errors potential medication-related

There is continued focus on adverse drug events and medication errors. Processes must respond to actual or potential adverse drug events and medication errors and properly report them internally and externally (e.g., to the FDA, ISMP, or USP). Other standards address how adverse drug events and medication errors should be addressed to improve systems, support staff education and training, and minimize the risk of medication-related errors and adverse events. 

In many instances, this interaction and others quite similar take place on a daily basis, but the valuable contributions pharmacists make in averting potentially lethal medication-related errors are never captured. More importantly, without this systematic approach to documentation of specific classes of agents, most common reasons for interventions and outcomes of recommendations would not be known or available for follow-up. 

JCAHO Sentinel Event Alert No. 23 Medication errors related to potentially dangerous abbreviations, September 2001. Available at www.jcaho.org, accessed August 5, 2002. 

A focus on reducing redundancy and the potential for fatal and nonfatal medical errors and preventable drug-related morbidity in all practice settings... 

Other pharmacoeconomic factors to consider include morbidity and mortality of transfusion reactions, related infections, potential for medical errors, and availability of RBCs as a resource. Length of ICU and total hospital stay and length of time on mechanical ventilation are also key factors. 

Five types of safety-related behaviors have been defined by Davis et al. [7] continuous versus on-off proactive versus reactive interactive versus noninterac-tive confrontational versus nonconfrontational and behaviors to prevent errors of omission versus errors of commission. For example, a patient asking a health care professional to check that they have received the correct medication involves the patient asking a question to prevent a medication error. The action comprises the following characteristics continuous, proactive, interactive, confrontational, and preventing a potential error of commission. In this example, patient participation could be facilitated by encouragement to challenge the clinician s competence, and there is evidence in the context of medication safety and infection control that provides some support for this view [8]. 

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