Alerts and Actions

July 2006

Preventing Medication Errors - recommendation highlights

The Institute of Medicine's recently released report, part of the Crossing the Quality Chasm series, sets a national agenda for change to reduce the risk of preventable harm that is too often associated with medication use. Actions that foster immediate and long-term solutions are listed.  Sections of the report apply to every aspect of the healthcare industry - providers, vendors, regulators and consumers.  If you don't read the entire report, at least take time to read the online Executive Summary.

A paradigm shift in the patient-provider relationship
The report emphasizes that one of the most effective ways to reduce medication errors is to create more of a partnership between patients and the health care system.  Among a list of strategies to help patients become better educated about their medicines and take more responsibility for monitoring the effects of the medicines, the report emphasizes that providers must take steps to educate, consult with and listen to patients.

Using information technology to reduce medication errors
The report call for health care organizations to become high-reliability organizations preoccupied with improving medication safety.  They recommend taking advantage of the latest information technologies and the most up-to-date organizational and management strategies - putting into place effective internal monitoring systems for detecting and preventing adverse drug events.

Acting on the data to prevent future errors

Medication error databases at all levels should have a greater ability to track effective

methods for preventing the errors described, with a requirement to report on follow-up actions taken and their effectiveness.  Time spent detecting, reporting, and analyzing medication errors and ADEs is wasted if the resulting information is not used to prevent future errors and injuries.

Talking Points

1. Health care providers can take a number of actions to promote successful medication error reporting regardless of their setting. First, they can create a learning system whereby errors and recommended preventive measures are reported and used as a tool for learning. Second, they can make a commitment to learning about error problems, monitoring national trends and reports,

   and implementing plans designed to prevent similar errors from occurring at their site. Third, when errors are identified, reporting should be encouraged.

2. The new patient-provider relationship is based on a re-balancing of the power in favor of patients. Patient rights include:

• Expecting providers to tell them when a clinically significant error has occurred, what the effects of the event on their health (short- and long-term) will be, and what care they will receive to restore their health.
• Asking their provider to report an adverse event and give them information about how they can report the event themselves.

SecondStory™ adverse event information technology and the Pharmacy Quality Assurance Program and Learning System™ are ideal practical tools to help organizations become preoccupied with improving safe medication use and improving the safety climate in their practices.

References

Click here to read the entire IOM report online.