Ten Ways to Improve Medication Safety

The United States Pharmacopeia (USP), an organization that, among other things, operates MEDMARX, the national, Internet-accessible anonymous reporting database that hospitals and health care systems may voluntarily use to track and trend medication errors, last month published 10 recommendations for cutting down medication errors in hospitals and health care facilities. They are:

1) Engage the CEO, administrators, and medical director in medication safety efforts. This involvement will help facilitate necessary culture and policy changes, helping to ensure that medication safety is a priority.

2) Adopt a nonpunitive policy for reporting potential and actual medication errors. Dissociate the performance appraisal system from the medication error reporting system. These policies build trust and eliminate the fears that prevent error reporting.

3) Provide incentives for your medication safety reporting system. Educate staff members on the importance of error reporting and institute programs that express appreciation for reporting efforts.

4) Create a multidisciplinary committee that meets regularly to examine medication error trends and suggest process improvements. Error analysis should be integrated in order to identify better practices and solutions.

5) Create open lines of communication among departments and disciplines. Staff members must feel comfortable discussing and resolving issues with pharmacists, physicians, nurses, and others.

6) Provide multiple methods for staff members to report errors and suggest improvements for safe medication use. Telephone hotlines and regular hospital rounds by administrators can be an effective means for staff members to raise safety issues.

7) Share information obtained from medication error reports with staff members, at least in aggregate form. By sharing information, the importance of the overall patient safety effort increases.

8) Standardize and simplify procedures and protocols. Be careful to balance process simplification with double checks for critical procedures.

9) Minimize distractions while nurses are preparing or administering medications. Establish separate rooms for nurses to prepare medications or create a system to take phone messages for nurses on medication rounds.

10) Work to change state laws where necessary. Work with legislators, task forces and others to develop guidelines compatible with a nonpunitive reporting environment

The United States Pharmacopeia (USP), an organization that, among other things, operates MEDMARX, the national, Internet-accessible anonymous reporting database that hospitals and health care systems may voluntarily use to track and trend medication errors, last month published 10 recommendations for cutting down medication errors in hospitals and health care facilities. They are:

1) Engage the CEO, administrators, and medical director in medication safety efforts. This involvement will help facilitate necessary culture and policy changes, helping to ensure that medication safety is a priority.

2) Adopt a nonpunitive policy for reporting potential and actual medication errors. Dissociate the performance appraisal system from the medication error reporting system. These policies build trust and eliminate the fears that prevent error reporting.

3) Provide incentives for your medication safety reporting system. Educate staff members on the importance of error reporting and institute programs that express appreciation for reporting efforts.

4) Create a multidisciplinary committee that meets regularly to examine medication error trends and suggest process improvements. Error analysis should be integrated in order to identify better practices and solutions.

5) Create open lines of communication among departments and disciplines. Staff members must feel comfortable discussing and resolving issues with pharmacists, physicians, nurses, and others.

6) Provide multiple methods for staff members to report errors and suggest improvements for safe medication use. Telephone hotlines and regular hospital rounds by administrators can be an effective means for staff members to raise safety issues.

7) Share information obtained from medication error reports with staff members, at least in aggregate form. By sharing information, the importance of the overall patient safety effort increases.

8) Standardize and simplify procedures and protocols. Be careful to balance process simplification with double checks for critical procedures.

9) Minimize distractions while nurses are preparing or administering medications. Establish separate rooms for nurses to prepare medications or create a system to take phone messages for nurses on medication rounds.

10) Work to change state laws where necessary. Work with legislators, task forces and others to develop guidelines compatible with a nonpunitive reporting environment