Omission of High-Alert Medications: A Hidden Danger.

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.

BACKGROUND: External reporting of medical errors a adverse events enables learning from the errors of others in the pursuit of systems-level improvements that can prevent future errors. It is logical to presume that medication errors involving the use of anticoagulants, among the most frequently cited product classes involved in harmful medication errors, would be captured in a variety of patient safety reporting programs. METHODS: Data on reported errors involving the anticoagulant heparin were reviewed, compared, and aggregated from the databases of three large patient safety reporting programs-MEDMARX, the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, and the University Health System Consortium, together representing more than 1,000 reporting organizations for 2005 RESULTS: Approximately 300,000 medication errors and near misses were reported to the programs, and 10,359-a mean of 3.6% (range, 3.1%-5.5%)-involved heparin products. The proportion of heparin-related reports that involved patient harm ranged from 1.4% to 4.9%. The phase of the medication use process cited most frequently in harmful events was the administration phase (56% of errors leading to harm), followed by the prescribing phase (19% of errors leading to harm). DISCUSSION: This study represents the first attempt by these three large reporting systems to combine data on a single clinical process. The consistent patterns evident in the reports, such as the percentage of all medication errors that involved heparin, suggests that reporting programs, at least for common events such as medication errors, may reach a point of diminishing returns in which aggregating more reports of a certain type yields no additional insight once a large volume of similar events is captured and analyzed.

Reducing the risk of medication errors in women.

We outline some of the causes of medication errors involving women and recommend ways that healthcare practitioners can prevent some of these errors. Patient safety has become a major concern since the November 1999 release of the Institute of Medicine (IOM) report, "To Err Is Human." Errors involving prescription medications are responsible for up to 7000 American deaths per year, and the financial costs of drug-related morbidity and mortality may be nearly $77 billion a year. The Institute for Safe Medication Practices (ISMP) collects and analyzes voluntary confidential medication error reports and makes recommendations on the prevention of such errors. This paper uses the expertise of ISMP in medication error prevention to make recommendations to prevent medication errors involving women. Healthcare practitioners should focus on areas of the medication use process that would have the greatest impact, including obtaining complete patient information, accurately communicating drug information, and properly educating patients. Although medication errors are not more common in women, there are some unique concerns with medications used for treating women. In addition, sharing of information about medication use and compliance with medication regimens have been identified as concerns. Through the sharing of information and improving the patient education process, healthcare practitioners should play a more active role in medication error reduction activities by working together toward the goal of improving medication safety and encouraging women to become active in their own care.

The role of managed care pharmacy in reducing medication errors.

OBJECTIVE: To outline some of the causes of medication errors and recommend ways that managed care pharmacy organizations and managed care pharmacists can prevent some of these errors through practitioner and patient education. BACKGROUND: Patient safety has become a major concern since the November 1999 release of the Institute of Medicine (IOM) report, To Err Is Human. Errors involving prescription medications are responsible for up to 7,000 American deaths per year and the financial costs of drug-related morbidity and mortality may cost nearly $77 billion US dollars a year. The Institute for Safe Medication Practices (ISMP) collects and analyzes voluntary confidential medication error reports and makes recommendations on the prevention of these errors. This article uses the expertise of ISMP in medication error prevention to make recommendations on educational programs for patients and managed care and community pharmacists to reduce medication errors in the outpatient (community) setting. These educational areas focus on patient education, compliance, and health care literacy. CONCLUSION: Managed care pharmacy is well positioned to affect change in the health care system. Through information dissemination and education, managed care pharmacists should play a more active role in medication error-reduction activities by improving the patient education process and in assisting the pharmacy community in its goal of improving patient safety.