BOX D-1

Organizations with Published Prevention Strategies for Hospital Care

  • Agency for Healthcare Research and Quality (Shojania et al., 2001)

  • American Society of Health-System Pharmacists (American Society of Health-System Pharmacists, 1996)

  • Institute for Healthcare Improvement (IHI, 2005)

  • Institute of Medicine (IOM, 2000)

  • Institute for Safe Medication Practices (ISMP, 2005b),

  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2005a)

  • Massachusetts Coalition for the Prevention of Medical Errors (MCPME, 1999)

  • National Quality Forum (NQF, 2003)

  • National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP, 2005b)

  • Pathways for Medication Safety (Pathways for Medication Safety, 2002)

  • U.S. Pharmacopeia (USP, 2005)

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) selects its patient safety goals from a pool of recommendations that are first identified by members of the Sentinel Event Advisory Group. These recommendations are selected because they are considered either evidence-based or, much more typically, consensus-based or practical. Similarly, the Institute for Safe Medication Practices generally develops its guidelines based on careful analysis of reported errors. These recommendations are then peer-reviewed prior to their release.

Recommendations for preventing medication errors are made by the National Coordinating Council for Medication Error Reporting and Prevention’s committee of experts in the field. The Massachusetts Coalition for the Prevention of Medical Errors developed best-practice recommendations for the prevention of medication errors based on a special consensus panel. The American Society of Hospital Pharmacists (ASHP) convened a

multidisciplinary conference on preventing medication errors. Recommendations from the ASHP derive largely from these expert panels. Along with the ASHP, both the American Medical Association and the American Nurses Association participated in this multidisciplinary conference.

Recommended Approaches

Table D-1 summarizes the error reduction strategies recommended by the organizations listed in Box D-1. In general, most organizations



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