Medication Errors

Bring medication errors out of the closet

Avoid finger-pointing at all costs

Identifying medication errors and their causes may seem like a separate task from voluntarily reporting them to the Joint Commission on Accred itation of Healthcare Organizations in Oakbrook Terrace, IL, the U.S. Pharmacopeial Convention (USP) in Rockville, MD, or another outside agency such as the U.S. Food and Drug Administration (FDA). But medication error specialists say systems should be designed with both tasks in mind.

Set up your system with the types of paperwork, categories, definitions, and even jargon that match those of the Joint Commission or other agencies. That - and getting hospital administrators and interdisciplinary teams in place as part of an error prevention, tracking, and reporting system - can help counter the "dirty little secret" status medication errors tend to acquire. Then, when something bad happens, it can be attacked as a system error without turning into a case of finger-pointing.

The following models are available to help you develop a system approach:

· The Joint Commission has a new framework for root-cause analyses as part of its new sentinel events reporting system. (See "The Quality-Co$t Connection" on p. 112 for more on sentinel events.)

· The American Society of Health-System Pharmacists (ASHSP) in Bethesda, MD, has a new model in diagram form that offers terminology and shows relationships among medication errors, adverse reactions, and adverse events. ASHSP's Web site is located at

· The U.S. Pharmacopeial Convention (USP) in Rockville, MD, offers the National Coordinating Council on Medication Error Reporting. Also available at the USP's Web site (http://www. is MedMARx, a database that anonymously collects, tracks, and benchmarks error data. Hospitals can track and monitor internal data with the goal of reducing similar events. They can also measure and compare their own experiences with those of other participating facilities and share solutions and policies. MedMARx also provides the ability to automatically document root-cause analyses in a hospital's own system using Joint Commission framework.