Medication errors enhancing

The FDA enhanced its efforts to reduce medication errors by dedicating more resources to drug safety, which included forming a new division on medication errors at the agency in 2002. FDA works to prevent medication errors before a drug reaches the market and monitors any errors that may occur after that, says Jerry Phillips, R.Ph., former director of the FDA s Division of Medication Errors and Technical Support. 

Safety reporting A proposed revamping of safety reporting requirements aims to enhance the FDA s ability to monitor and improve the safe use of drugs and biologies. In 2003, the FDA published a proposed rule. The rule, if enacted, would improve the quality and consistency of safety reports, require the submission of all suspected serious reactions for blood and blood products, and require reports on important potential medication errors. 

Several key factors drive the need for automation. A national shortage of pharmacists in the face of ever-increasing prescription volumes is one major impetus. Another is the profound need to reduce the incidence of medication errors. Still another is the opportunity created by automation to enhance the role of pharmacists in patient care. Finally, consumers demand for speed and convenience further enhances the attractiveness of automation in pharmacy operations (Lewis, Albrant, and Hagel, 2002). Technology has the ability to accelerate the movement of pharmacists from the traditional dispensing focus to that of a patient-centered role. 

This chapter focuses on system enhancements and the checks and balances needed to proactively prevent medication errors as pharmacists and technicians prepare, dispense, and monitor the effects of medications in all practice settings. In addition, focus is placed on the importance of determining latent failures that contribute to mediation errors by developing effective medication error reporting programs to discover how latent failures occur and how they can be prevented. 

These lOM reports can serve as stimuli for the pharmacy profession to initiate improvements in the quality of care delivered to patients and to reduce the extent and severity of medical errors within the U.S. This is an opportunity for pharmacisfs to institute improvements from within the profession, instead of waifing for imposed changes from other health professions, industries, or regulatory bodies. Pharmacists are trained with a xmique set of skills and expertise regarding medication use. Working as part of a team of health care professionals, these skills can be used to better serve the public, lead to improvements in the quality of care, and enhance the professional aspects of pharmacy practice. 

The traditional system of providing patient care— wherein physicians initiate drug therapy, pharmacists dispense medications, and nurses administer medica-tion.s—is often run in a disjointed fashion. This results in potentially avoidable adverse drug events that contribute to poor patient outcomes and increased medical costs. Efforts aimed at modifying the current processes of care to enhance efficiency of workflow, improve patient outcomes, and reduce medication errors arc needed. 

To enhance the quality, appropriateness, and effectiveness of health care services, and access to these services the federal government in the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) established the AHCPR. The act, sometimes referred to as the Patient Outcome Research Act, called for the establishment of a broad-based, patient-centered outcomes research program. In addition to the traditional measures of survival, clinical endpoints and disease- and treatment-specific symptoms and problems, the law mandated measures of functional status and well-being and patient satisfaction. In 1999, then President Clinton signed the Healthcare Research and Quality Act, reauthorizing AHCPR as the AHRQ until the end of fiscal year 2005. Presently, its mission is to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, broaden access to effective services, and improve the quality of health care services. 

It is the mission of ISMP—Spain to enhance the safety of the medication-use system and to improve the quality of patient healthcare. The most important goal is to reduce the risk of medication errors and preventable adverse drug events. 

Much of the knowledge developed about medication errors and ADEs has depended on the ability of individual pharmacists to detect problems and take an active part in resolving them. The increasing use of complex medication regimens has drawn attention to the number of iatrogenic medication errors and ADEs, as well as their associated costs. Pharmacists must work to reduce predisposing factors so that safety can be enhanced and costs reduced. A new practice model as an adjunct to evidence-based medicine practices must be created to prevent medication errors and ADEs, and to let others outside the pharmacy know that we are ready to lend our expertise and energy to this critical endeavor. 

Classen, D.C. Adverse Drug Events and Medication Errors The Scientific Perspective. In Proceedings of Enhancing Patient Safety and Reducing Errors in Health Care, National Patient Safety Foundation Chicago, 1998 56-60. 

Role that expands beyond standards Unlike most of the world s major pharmacopeias, USP s role is not limited to the establishment of written and chemical pharmacopeial standards. USP also helps to monitor and prevent medication error problems through reporting programs for healthcare professionals. The valuable information and feedback obtained through these programs enables USP to enhance the accuracy and utility of its standards. 

HIT can enhance patient safety in three ways it can help prevent medical errors and adverse events it can initiate rapid responses to any event and it can enable the tracking of events, if they occur, and provide feedback on them to learn from [30]. But it is the first of these which is of most interest when it comes to proactively reducing the risk of harm. If we can identify the conditions in which dangerous scenarios occur we have a vital window of opportunity to intervene in the natural history of a hazard (see Sect. 2.6). 

Lanham, B., Maxson-Cooper, R, Is Six Sigma the Answer for Nursing to Reduce Medical Errors and Enhance Patient Safety , Nursing Economics, Vol. 21, No. 1, 2003, pp. 39-41. 

Froedtert began its involvement with Six Sigma by forming a consortium with the American Society for Quality (ASQ) and the Medical College of Wisconsin. The goal was to pilot the application of Six Sigma to health care to reduce medical errors and enhance patient safety. 

Froedtert now plans to become a "Six Sigma Organization," which involves expanding the use of the Six Sigma methodology to encompass reduction of medical errors, promotion of patient safety, cost reduction, and enhancement of process efficiency. 

Hydroxyamphetamine provides a clearer distinction between preganglionic and postganglionic defects than does any other mydriatic test. Although the hydroxyamphetamine test is not subject to error because of fectors that tend to enhance corneal penetration, the results of this test may be somewhat ambiguous when the Horner s syndrome is incomplete. Because pretreatment with cocaine interferes with the action of hydroxyamphetamine, at least 2 days should elapse after cocaine administration before proceeding with the hydroxyamphetamine test.The pupils should be observed at 45 to 60 minutes after the medication is instilled. 

APhA has several affiliate organizations, and through the work of its Foundation and credentialing organizations, the Association has made a major commitment to research, quality measurement, and accountability. The APhA Foundation has sponsored and directed several significant research and demonstration projects to contribute to the body of evidence that pharmacists services enhance patient health-seeking behavior and improve outcomes. Research on quality measurement and the development of tools to reduce medication use problems and errors is a priority of the Foundation. 

In 1983 Neil McIntyre, Professor of Medicine, and the philosopher Sir Karl Popper, published a paper The critical attitude in medicine the need for a new ethics, which called for clinicians to actively seek out errors and use them to advance both their personal knowledge and medical knowledge generally. This paper is densely, almost unbelievably, rich in ideas and embraces ethics, philosophy of science, the doctor-patient relationship, attitudes to fallibility and uncertainty, professional regulation and methods for enhancing the quality of care. Summarizing all the arguments is not feasible, but two extracts illustrate some of the main themes ... 

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