Patient safety error

Erlen, J. A., Patient Safety, Error Reduction, and Ethical Practice, Orthopaedic Nursing, Vol. 26, No. 2, 2007, pp. 130-133. 

Patient safety errors are rising nationally and merit urgent attention. But the numbers themselves do not tell healthcare leaders what they should do. What does it take to create a... 

QulC, Report of the Quality Interagency Coordination Task Force (QulC) to the President. Doing What Counts for Patient Safety Federal Actions to Reduce Medical Errors and Their Impact, February 2000, Rockville, MD (http //www.quic.gov/report). 

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. 

In addition, the U.S. Department of Health and Human Services (HHS) and other federal agencies formed the Quality Interagency Coordination Task Force in 2000 and issued an action plan for reducing medical errors. In 2001, former HHS Secretary Tommy G. Thompson announced a Patient Safety Task Force to coordinate a joint effort to improve data collection on patient safety. The lead agencies are the FDA, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and the Agency for Healthcare Research and Quality. 

It s a promising way to automate aspects of medication administration, says Robert Krawisz, former executive director of the National Patient Safety Foundation. The technology s impact at VA hospitals so far has been amazing. The Department of Veterans Affairs (VA) already uses bar codes nationwide in its hospitals, and the result has been a drastic reduction in medication errors. For example, the VA medical center in Topeka, Kan., has reported that bar coding reduced its medication error rate by 86 percent over a nine-year period. 

Gaba DM. Physician work hours the sore thumb of organizational safety in tertiary health care. In Scheffler AL, Zipperer LA, eds. Enhancing Patient Safety and Reducing Errors in Health Care. Chicago National Patient Safety Foundation, 1998 302-305. 

SIG (prescription instructions), and RxNorm (standard name, dose, and form availability) were not considered ready for implementation because of numerous approaches used in these three areas across health information technology. Electronic prescribing is not required under MMA, but plans are to have it available should providers choose to use it. As standards are developed, the adoption of e-prescribing is expected to improve patient safety by reducing prescribing and dispensing errors (Agency for Healthcare Research Quality, 2007). 

Riskprevention/mModijication. Pharmacy managers may not be able to eliminate a risk, but they can take steps to minimize the likelihood of its occurrence. All pharmacies take steps to avoid medication dispensing errors. This commonly involves the development of policies and procedures to prevent errors and improve patient safety (see Chapters 7 and 30). 

Identify specific problems in our approach to error prevention and what needs to be changed to ensure patient safety. 

For nearly 33 years, the USP has been reporting programs for health care professionals to share experiences and observations about the quality and safe use of medications. This year, the USP Center for the Advancement of Patient Safety publishes its sixth annual report to the nation on medication errors reported to MED MARX (Table 6). It was observed that drug product packaging/labeling is one of the main courses of medication errors in hospitals. 

Systems that are well thought out include clear policies and procedures to guide practihoners. Deliberate violahons of these guidelines can lead to errors. Pharmacists can prevent errors and increase patient safety by using safe practices. 

Accrediting organizations emphasize patient safety as a fxmdamental issue. The federal Centers for Medicare and Medicaid Services includes monitoring of medication errors as part of their conditions of participation, noting that the medical staff is responsible for developing policies and procedures that minimize drug errors. This fxmction may be delegated to the hospital s... 

The Medication Error Reporting Program (MERP) is a voluntary program administered by the U.S. Pharmacopeia (USP) in conjxmction with the ISMP. This confidential reporting system improves patient safety by alerting practitioners and the industry to potential or actual problems. Practitioners are asked to report errors and near misses to this program so that others learn from errors and prevent similar errors in the future. 

To Err Is Human contains a four-part plan for decreasing the number of medical errors, and each part has implications for the pharmacy profession. To provide leadership and a research focus for patient safety. Part one recommends the creation of a center for patient safety within the Agency for Healthcare Research and Quality (AHRQ). Pharmacy organizations and pharmacists have the opportunity to contribute by including the study of medical errors in their applied research agendas. Using their expertise, pharmacists can provide input to the national goals, their content, and professional responsibilities for medicahon safety. ... 

Because of its potential to have a considerable impact on patient safety, artwork processes generally involve several stages of critical checks within the pharmaceutical organization to ensure that the final copy is as error free as possible. The completion of these checks is recorded in supporting workflow applications at key checkpoint stages. 

ASHP Issue Paper. Lssue Patient Safety and Medical Errors, Bethesda, Maryland, 2000. http //www.ashp.org/ public/proad/psrne.pdf. 

Since its establishment in 1989, AHRQ has sponsored and conducted research to improve the quality of health care, reduce its cost, and increase access. It also supports research to address patient safety issues and medication errors. AHRQ s goal is to provide information that allows people to make better decisions about healthcare. 

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. 

Collaborative work toward error prevention with the American Hospital Association (AHA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Coordinating council on Medication Error Reporting and Prevention (NCCMERP), the National Patient Safety Foundation (NPSF), the United States Pharmacopeia (USP), and dozens of other consumer and professional organizations. 

The edueation and dissemination of information is another primary objective of ISMP—Spain If everyone understands the nature and causes of medication errors, there is a much greater possibility of improving patient safety. In this sense, ISMP—Spain makes educational presentations and holds conferences at healthcare professional meetings to provide information about adverse drug events. ISMP—Spain also publishes opinion articles and practical articles in Spanish healthcare journals in an effort to broadly disseminate a culture of safety and error prevention. 

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