Bringing med errors out of the closet
Bringing med errors out of the closet
Tracking, reporting models are emerging
Identifying medication errors and causes in your system and then reporting them to outside agencies such as the U.S. Food and Drug Administration or an accreditation body may seem like two separate tasks. But more and more medication error specialists say pharmacists should design their systems with both tasks in mind.
In other words, set up your system with the types of paperwork, categories, definitions, and even jargon that match the outside agency you report to. 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 and adverse reactions can’t completely shake. Then, when something bad happens, it can be attacked as a system error without turning into a case of fingerpointing.
"A lot of hospitals have very punitive punishments if a practitioner makes an error. And then you have state board hearings and even the criminal courts," says Mike Cohen, president of the Institute for Safe Medication Practices (ISMP) in Warminster, PA. "And these are real negatives that are not going to help society. Errors won’t get reported, they will be swept under the carpet, and it’s a very dangerous situation."
But for those willing to develop a system approach, models are available. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has a new Framework for Root Cause Analysis as part of its new sentinel events reporting system. (See box, p. 41, and insert.)
The American Society of Health-System Pharmacists has a new Web page model in diagram form that offers terminology and shows relationships between medication errors, adverse reactions, and adverse events. The Internet address is: www.ashp.org. Also, the U.S. Pharmacopeial Convention (USP) offers the National Coordinating Council on Medication Error Reporting.
Anonymity and outside help
The California Pharmacists Association (CPhA) has become the first state organization to team with the USP to set up a tracking and reporting study. The effort is twofold: to get a handle on whether medication errors are increasing as suspected, and to determine whether pharmacist workloads and the use of technicians are playing a role in the problem.
Using the USP’s system and standard reporting forms, the effort will help USP in its effort to compile a national medication error database. To date, nearly a thousand California pharma-cists have been mailed the reporting forms. Additionally, informational letters outlining the effort were sent to members of the Guild for Professional Pharmacists in California.
A previous anonymous survey by the guild found an error rate of one per 285 orders in California. The survey sought input from 23,000 pharmacists, but its return rate of 14% was deemed too low to take the results to the state’s board or legislature for any action, according to guild president Ralph Vogel.
With the new effort, based again on anonymity and help from an outside agency, organizers are hoping pharmacists will feel more secure about responding, says CPhA CEO Carlo Michelotti. He had no time frame for when the results would be ready for publication.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.