USP 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... 

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. 

USP s anonymous medication error reporting program used by hospitals. 

Report any information relating to medication errors to the Medication Errors Reporting Program operated by USP convention [10] and the Institute for Safe Medication Practice (ISMP) or other corresponding institutions in the different countries. The program shares information on medication errors with health care professionals to prevent similar errors from recurring. 

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. 

Independent review of all errors reported to the USP-ISMP Medication Errors Reporting Program (MERP) and acting partner in the FDA s MedWatch Program. 

The Institute of Medicine (lOM) estimates that between 44,000 and 98,000 deaths annually in the U.S. result from medical errors. While there is some debate about this estimate, it is clear that medication errors are common and result in significant adverse effects, including death. Databases of anonymously reported errors are maintained jointly by the Institute for Safe Medication Practices (ISMP), the U.S. Pharmacopeia Medication Errors Reporting Program (USP MERP), and the FDA s MedWatch program. Adverse drug events occm in 3% of hospitalizations, and this number is larger for special populations such as those in pediatric and neonatal intensive care units. 

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 ). 

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. 

Thorough documentation of medication errors provides information about the severity of the error as it relates to the effeet on the patient, the product(s) involved, the competence of staff handling the produet or proeessing the order, any contributing factors that may predispose a product to misuse, and the suspected root cause of the error. USP adds certain codes to MER Program data in order to characterize the error as it was reported. These codes include the type of error and the possible eause(s) of error. The following list shows some of the produet eharaeteristics that have been recorded over 9 years to have caused or eontributed to a medication error. 

The Council encourages health care professionals to report actual and potential medication errors to national (e.g., FDA MedWatch Program and/or the USP Practitioners Reporting Network), internal, and local reporting programs. 

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. 

In 1996, the USP created an ad hoc Advisory Panel on Medication Errors. The mission of the Panel was to provide practitioner review of reports received through the USP MER Program and to make recommendations relative to USP s standards-setting, information, and reporting programs. The Panel chairperson also has a unique opportunity to make broader recommendations through its seat on the National... 

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