Reporting Medication Errors

Discuss the importance in participating in the MedWatch programs and the Medication Errors Reporting Program. 

USP MEDICATION ERRORS REPORTING PROGRAM Presented in cooperation with the Institute for Safe Medication Practices The USP Practitioners Reporting Network is an FDA medWatch partner... 

Appendix C contains a United States Pharmacopeia (USP) medication errors reporting program form, which is used by health care professionals for sharing information of medication errors to prevent them from occuring again. Also included is text explaining medication error and the USP... 

Antonow, J.A., Smith, A.B. and Silver, M.P. (2000). Medication error reporting A survey of nursing staff. J. Nursing Care Quality 15 42 18. 

Prevention of medication errors is the primary objective of the USP Medication Errors Reporting Program. It collects and analyzes potential and actual medication errors submitted by health care practitioners. The program affords health care professionals the opportunity to report medication errors and thereby contribute to improving patient safety by sharing their experiences. 

Medication error information submitted to USP is entered into a nationally recognized repository for medication error reporting. This database serves to track, monitor, and analyze medication errors from a systems-based perspective. The USP develops educational resources and materials to disseminate best practice solutions and error-avoidance strategies to students and practitioners. 

Stimulation of development and use of medication error reporting and evaluation systems and stimulation of reporting to a national system for review, analysis, and development of recommendations to reduce and prevent medication errors... 

TABLE 1 National Coordinating Council for Medication Error Reporting and Prevention, Organizations Represented... 

USP received a medication error report involving the products Neumega (oprel-vekin) and Proleukin (aldesleukin). Oprelvekin, a recombinant human interleukin-11 product used to stimulate platelet production in selected patients undergoing chemotherapy, is sometimes abbreviated as IL-11. Aldesleukin, a recombinant human interleukin-2 derivative indicated in designated patient populations for the treatment of metastatic renal-cell carcinoma, is sometimes abbreviated as IL-2. 

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer, according to the National Coordinating Council for Medication Error Reporting and Prevention. The council, a group of more than 25 national and international organizations, including the FDA, examines and evaluates medication errors and recommends strategies for error prevention. 

Error tracking and public education The FDA reviews medication error reports that come from drug manufacturers and through MedWatch, the agency s safety information and adverse event reporting program. The agency also receives reports from the Institute for Safe Medication Practices (ISMP) and the U.S. Pharmacopeia, or USP (see Who Tracks Medication Errors ). 

The FDA receives and reviews about 300 medication error reports each month and classifies them to determine the cause and type of error. Depending on the findings, the FDA can change the way it labels, names, or packages a drug product. In addition, once a problem is discovered, the FDA educates the public on an ongoing basis to prevent repeat errors. 

USP s anonymous medication error reporting program used by hospitals. 

It was reported by the Institute for Safe Medication Practices (ISMP) in 2000 that fewer than 5 percent of physicians were writing prescriptions electronically. In a 2000 white paper entitled, A Call to Action Eliminate Handwritten Prescriptions within 3 Years, ISMP recommended the use of electronic prescribing by clinician order entry to reduce medication errors (ISMP, 2000). CPOE can help to reduce errors in the delivery and transcribing of orders to the pharmacy where the orders are filled. Order management can be used to control inventory and alert pharmacy staff (and even the patient) of the status of a prescription. For example, some national chain pharmacies have the capability of alerting the patient by phone or e-mail if a prescription is ready or if other action needs to be taken before the prescription can be picked up. The system should also be able to report results, such as the number of prescriptions filled, the revenue generated over a specified time, and medication error reports. 

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. 

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