above settings, although the way it is implemented will vary by setting, as will the medication-use systems and the errors and adverse drug events (ADEs) that may occur. In the inpatient setting, for example, major safety issues include medication selection and administration (Bates et al., 1995a). By contrast, in nursing homes and the outpatient setting, monitoring is especially important (Gandhi et al., 2003; Gurwitz et al., 2000, 2003). In all settings, access to patient-specific and reference information is central to delivering safe medication-related care.

Actions identified by the committee that can be taken to improve medication safety by individual prescribers are summarized in Box 5-1, by individual pharmacists in Box 5-2, and by individual nurses in Box 5-3. The committee’s recommendation for systemic changes across health care settings is then presented. The remainder of the chapter provides a detailed discussion of the specifics of this recommendation.

Many of the actions for providers listed in Boxes 5-1 to 5-3 are recommended by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Quality Forum (NQF). Since 2003, JCAHO has set annual National Patient Safety Goals (JCAHO, 2005) and included a survey of compliance with the requirements as part of the accreditation process. Many of the National Patient Safety Goals relate to medications (see Box 5-4). The Agency for Healthcare Research and Quality (AHRQ) requested that the NQF use an expert consensus process to define a list of best safety practices. The resulting NQF report, Safe Practices for Better Healthcare, listed 30 practices that should be universally adopted in applicable care settings, 13 of which involve the use of medications (see Box 5-5), and another 27 practices (15 of which are medication-related) that should receive high priority for additional research (NQF, 2003).

A number of additional key points should be emphasized. First, having a safety culture is pivotal to improving medication safety. To institute a safety culture, senior management must devote adequate attention to safety and provide sufficient resources to quality improvement and safety teams. Senior management must also authorize resources to invest in technologies that have been demonstrated to be effective but are not yet widely implemented in most organizations, such as computerized provider order entry (CPOE) and electronic health records. It has become increasingly clear that the introduction of any of these technologies requires close attention to business processes and ongoing maintenance. A number of studies have shown that these tools can have unintended and adverse consequences, and that avoiding such consequences requires addressing business and cultural issues.

Improvements in the safe use of medications need to be implemented within the context of an overall quality improvement program, specifically



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