Safety medication error

ADEs and medication errors can be extracted from practice data, incidents reports from health professionals, and patient surveys. Practice data include charts, laboratory, prescription data, and administrative databases, and can be reviewed manually or screened by computer systems to identify signals. A method of ADE and medication error detection and classification has been presented that is feasible and has good reliability (Marimoto et al. 2004). It can be used in various clinical settings to measure and improve medication safety. 

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. 

Strategies to Reduce Medication Errors Working to Improve Medication Safety... 

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. 

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. 

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. 

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 ). 

Hospitals and other health care organizations work to reduce medication errors by using technology, improving processes, zeroing in on errors that cause harm, and building a culture of safety. Here are a couple of examples. 

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. 

Pharmacists and technicians play a major role in medication safety in modern pharmacy practice. After summarizing several studies performed in hospitals and long-term care facilities, Allan and Barker (1990) estimated that medication errors occur at a rate of about 1 per patient per day. In a more recent study performed in ambulatory pharmacies, they found an overall dispensing accuracy rate for prescription medications of 98.3 percent (Allan, Barker, and Carnahan, 2003). While most of these errors probably have minimal clinical relevance and do not affect patients adversely, many experts believe that medication error rates may be higher in the ambulatory care setting because errors may not always be evident to the health professionals who work there. For example, medication errors can occur when a patient purchases nonprescription medications without speaking with the pharmacist about any potential interactions with his or her prescription medications or if patients fail to verify the appropriate dose of the over-the-counter (OTC) medication. 

Multidisciplinary educational programs should be developed for health care personnel about medication error prevention. Because many errors happen when procedures are not followed, this is one area on which to focus through newsletters and in-service training. It also is important for pharmacy staff not just to focus on their own internal errors but also to look at other pharmacies errors and methods of prevention and to learn from them. Organizations such as the ISMP, USP, and many others provide ongoing features to facilitate these reviews in publications such as Hospital Pharmacy, Pharmacy Today, U.S. Pharmacist, and Pharmacy and Therapeutics or newsletters that report on current medication safety issues and offer recommendations for changes. 

The safety of the medication system is the primary concern of every hospital pharmacist. Recently published reports of the incidence, causes, and cost of injury resulting from medication errors have led many hospitals to critically evaluate their quality assurance systems (Bates et al., 1996, 1997 Classen et al., 1997 Kohn, Corrigan, and Donaldson, 1999 Leape et al., 1991, 1995 Poon et al., 2006 Stelfox, et al., 2006). Written incident reports were once the standard for gathering information about medication misadventures. This method is now believed to lack sufficient completeness and reliability for identifying weaknesses in a medication system (Classen et al., 1991 Cullen et al., 1995 Leape, 1994, 2002 Leape et al., 1995). 

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. 

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