the committee learned about a wide variety of communication opportunities and challenges related to involving the general public and disease groups (such as online support groups) in reporting drug-related adverse events, about a movement to counteract commercial pharmaceutical company “detailing” with neutral “academic detailing” (Avorn, 2005), about First Amendment-based opposition to calls for increased FDA regulation (including banning) of DTC advertising, etc.

Providers, including physicians and pharmacists, are encouraged to report adverse drug reactions experienced by their patients to the manufac-

  • The NLM should take the lead in developing a common drug nomenclature for use in all clinical information technology systems based on the standards for the national health information infrastructure.

  • AHRQ should take the lead in organizing safety alert mechanisms by severity, frequency, and clinical importance to improve clinical value and acceptance.

  • AHRQ should take the lead in developing intelligent prompting mechanisms specific to a patient’s unique characteristics and needs; provider prescribing, ordering, and error patterns; and evidence-based best-practice guidelines.

  • AHRQ should take the lead in developing user interface designs based on the principles of cognitive and human factors and the context of the clinical environment.

  • AHRQ should support additional research to determine specifications for alert mechanisms and intelligent prompting, and optimum designs for user interfaces.

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, and to ensure that professionals have the competencies required to deliver medications safely.

  • 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.

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