Preventing Medication Errors (2007) / Chapter Skim
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8 Action Agendas for Oversight, Regulation, and Payment
8 Action Agendas for Oversight, Regulation, and Payment
Pages 328-348
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that shapes the behavior, interests, and opportunities of the organizations at level C Players at the environmental level include legislators, regulators, accreditors, payers, patient safety organizations,1 and educators.
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· Medication error reporting should be promoted more aggres sively by all stakeholders (with a single national taxonomy used for data storage and analysis)
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. There are, however, key roles in process improvement for legislators, regulators, accreditors, payers, and patient safety organizations.
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. The initiative covers five conditions (acute myocardial infarction, coronary artery bypass graft, heart failure, community
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The committee notes that a majority of the pay-for-performance and value-based purchasing initiatives undertaken to date have been for institutional care (for example, hospitals and nursing homes)
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. Among other services, medication therapy management may include formulating a medication treatment plan; selecting, initiating, modifying, or administering medication therapy; monitoring and evaluating the patient's response to therapy, including safety and effectiveness; performing comprehensive medication reviews to identify, resolve, and prevent medicationrelated problems, including adverse drug events (ADEs)
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, and electronic medication administration records (31 percent)
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The committee believes the California legislation discussed above is an important step toward the implementation of technologies for reducing medication errors. The committee believes further that this initiative should be expanded.
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The DHHS and the Drug Enforcement Administration are working on ways to enable electronic prescribing to encompass controlled substances, an effort the committee believes to be important. STATE PHARMACY BOARDS With a few exceptions, there is currently little or no oversight of community pharmacies related to medication safety.
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The New Mexico Board of Pharmacy is also active in providing information about preventing medication errors through its website (NMBP, 2005)
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The committee believes Congress should fund a study on the development and funding of a national medication error prevention effort in community pharmacies, coordinated by state pharmacy boards. REPORTING PROGRAMS FOR MEDICATION ERRORS/ADVERSE DRUG EVENTS In Chapter 2, external and internal error reporting programs were discussed briefly, while the committee's recommendations for internal monitoring programs were presented in Chapter 5.
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Computerized analysis of patient records using a database trigger system (see Chapter 5) will be an important way of identifying many medication errors, but will not eliminate the need for reporting programs.
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. The goals of this effort are to promote a national reporting system for adverse events through the use of a standardized patient safety taxonomy and ontology.
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and laboratory data. Data from the Part D program also have the potential to be a useful resource for understanding and preventing medication errors, especially for medication use by the elderly and the chronically ill (Platt and Ommaya, 2005)
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A 2001 survey of schools of pharmacy in the United States found that the quality and quantity of instruction in medication errors varied significantly, and that key domains of knowledge were lacking in some programs (Johnson et al., 2002)
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. · With the help of a grant from AHRQ, a continuing education curriculum in ambulatory care aimed at advancing patient safety and incorporating a medication errors module was developed (Mottur-Pilson, 2005)
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. The committee recommends that the relevant accreditation organizations -- the Liaison Committee on Medical Education, Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, Accreditation Council for Pharmacy Education, American Society of Health-System Pharmacists, National League for Nursing Accrediting Commission, and Commission on Collegiate Nursing Education -- ensure that the curricula of undergraduate and graduate pharmacy, nursing, and medical schools and continuing education include: · Appropriate medication safety modules to cover an overview of the system for drug development, regulation, distribution, and use; an understanding of where medication errors can take place; the need to monitor continuously for medication errors; how to recognize medication errors and the tools for identifying such errors; what to do once a medication error has been found; reporting and analysis of medication errors; and ways of improving the safety of the medication-use process.
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2005. The JCAHO patient safety event taxonomy: A standardized terminology and classification schema for near misses and adverse events.
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2002. Medication error instruction in schools of pharmacy curricula: A descriptive study.
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2005. New Mexico Board of Pharmacy: Adverse Drug Events and Medication Errors.
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Oakland, CA: California Healthcare Foundation. Teich JM, Osheroff JA, Pifer EA, Sittig DF, Jenders RA, The CDS Expert Review Panel.
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