Pharmacy group proposes system for error reporting

National system could reduce medication errors

The American Society of Health-System Pharmacists (ASHP) in Bethesda, MD, is proposing a national approach to reducing medication and other medical errors.

The ASHP, which represents 30,000 pharmacists who practice in hospitals and other components of health systems, is advocating the establishment of a national medical error reporting system and the strengthening of voluntary reporting systems.

"We need to move beyond the culture of blame that has traditionally surrounded the issue of medical error and begin to establish standardized reporting systems that take a lessons-learned’ approach to the problem," says ASHP president Bruce Scott, FASHP.

"The ideal system would allow sunshine into the processes that create error so that we can change those processes and protect patients," he adds.

The ASHP statement says a mandatory reporting system should only be applied when patients are seriously harmed or die as a result of error. "This system should focus on three primary goals: accountability, quality improvement, and enhancement of patient safety," Scott says.

Pharmacies play a role in error prevention

ASHP recommendations are in direct response to the Institute of Medicine’s recent report on medical error, "To Err is Human: Building a Safer Health System," which highlighted the important role of pharmacists in preventing medication errors, especially through their work on patient-care teams.

ASHP supports a mandatory medical error reporting system at the state level with strong federal coordination, analysis, and oversight. That system would focus on improving health care processes; providing confidentiality to patients, health care workers, and institutions as long as the confidentiality doesn’t compromise public accountability; and eliminating penalties for either the reporting of or involvement in a medical error that causes serious harm or death.

Standardizing reporting methods

The group also recommends the adoption of a definition of "serious harm" that focuses on incidents of long-term or irreversible patient harm. It also advocates that a mandatory system include national coordination and standardization of reporting methods and analysis, adequate resources for report analysis and quality improvement, and periodic assessment to ensure the system is working and not creating undesirable consequences.

ASHP also weighed in on the importance of maintaining and improving current voluntary reporting systems. The Society noted that the current Medication Errors Reporting Program operated by the U.S. Pharmacopeia in cooperation with the Food and Drug Administration’s MedWatch program and the Institute for Safe Medication Practices could serve as a model for voluntary reporting of other types of medical errors.