. "5 Action Agenda for Health Care Organizations ." Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007.
The following HTML text is provided to enhance online
readability. Many aspects of typography translate only awkwardly to HTML.
Please use the page image
as the authoritative form to ensure accuracy.
Data sources are screened for evidence that an error occurred
Medical record
Observation
Observer records medications administered and compares with orders, or observer shadows physician (Rothschild et al., 2005)
Personnel actions
Self-report, voluntary
Providers submit data about events
Patients, medical record
Self-report, prompted
Providers are interviewed to see whether any incidents have occurred
Providers
can create a learning system whereby errors and recommended preventive measures are reported and used as a tool for learning. Second, they can make a commitment to learning about error problems, monitoring national trends and reports, and implementing plans designed to prevent similar errors from occurring at their site. When errors and ADEs are identified, reporting should be encouraged. For example, the Institute for Safe Medication Practices’ (ISMP) Medication Safety Alert newsletter, United States Pharmacopeia (USP) MedMARx reports, and case studies from AHRQ’s Web M&M (http://www.webmm.ahrq.gov) should be required reading for health care practitioners, including community pharmacists, who can learn about errors that have occurred and take action to avoid them. Recommended preventive actions, based on expert review, are included in the ISMP newsletter.
As noted, voluntary reporting is valuable for identifying large problems and providing a stimulus for change, but has recognized limitations for evaluating the true frequency of medication errors and ADEs. In a comparison of voluntary reports against observation in 36 health care facilities, observation detected 456 times more errors (Flynn et al., 2002).
