Recommendation 7: Oversight and regulatory organizations and payers should use legislation, regulation, accreditation, and payment mechanisms and the media to motivate the adoption of practices and technologies that can reduce medication errors, as well as to ensure that professionals have the competencies required to deliver medications safely.

  • Payers and purchasers should continue to motivate improvement in the medication-use process through explicit financial incentives.

  • CMS should evaluate a variety of strategies for delivering medication therapy management.

  • Regulators, accreditors, and legislators should set minimum functionality standards for error prevention technologies.

  • States should enact legislation consistent with and complementary to the Medicare Modernization Act’s electronic prescribing provisions and remove existing barriers to such prescribing.

  • All state boards of pharmacy should undertake quality improvement initiatives related to community pharmacy practice.

  • Medication error reporting should be promoted more aggressively by all stakeholders (with a single national taxonomy used for data storage and analysis).

  • Accreditation bodies responsible for the oversight of professional education should require more training in improving medication management practices and clinical pharmacology.

The remainder of this chapter provides a detailed discussion of this recommendation.


In developing the above recommendation, the committee took the view that environmental-level stakeholders—legislators, regulators, accreditors, payers, patient safety organizations, and educational accreditors—should:

  • Encourage recognition that the use of drugs should take place in a learning environment in which there will always be more to learn about the balance of the effectiveness and safety of drugs in terms of both their intrinsic properties and the ways in which they can be used.

providers that collect, manage, and analyze patient safety data and advocate safety improvements on the basis of an analysis of those data.

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