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Appendix E Summary: Preventing Medication Errors: Quality Chasm Series, Institute of Medicine
Pages 267-308

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From page 267...
... Appendix E Summary Preenting Medication Errors: Quality Chasm Series Institute of Medicine 
From page 269...
... Preventing Medication Errors Committee on Identifying and Preventing Medication Errors Board on Health Care Services Philip Aspden, Julie A Wolcott, J
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... Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history.
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... "Knowing is not enough; we must apply. Willing is not enough; we must do." -- Goethe Advising the Nation.
From page 272...
... The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters.
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... COMMITTEE ON IDENTIFYING AND PREVENTING MEDICATION ERRORS J LYLE BOOTMAN (Co-chair)
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... WILSON D PACE, Professor of Family Medicine and Green-Edelman Chair for Practice-based Research, University of Colorado; Director, American Academy of Family Physicians National Research Network KATHLEEN R
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... Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge.
From page 276...
... viii REVIEWERS LUCIAN LEAPE, Department of Health Policy and Management, Harvard School of Public Health ART LEVIN, Center for Medical Consumers, New York, NY G STEVE REBAGLIATI, Department of Emergency Medicine, Oregon Health and Sciences University HUGH TILSON, School of Public Health, University of North Carolina Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release.
From page 277...
... Preface In 2000, the Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System raised awareness about medical errors and accelerated existing efforts to prevent such errors.
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... x PREFACE mendations for change that should be implemented and evaluated. People who use medications to meet their health care needs have a huge stake in that effort.
From page 279...
... The following individuals shared their research, experience, and perspectives with the committee: Tom Abrams, Food and Drug Administration; Bruce Bagley, American Academy of Family Physicians; Robert Ball, Food and Drug Administration; Jim Battles, Agency for Healthcare Research and Quality; Karen Bell, Centers for Medicare and Medicaid Services; Douglas Bierer, Consumer Healthcare Products Association; David Bowen, Office of Senator Edward Kennedy; Bill Braithwaite, eHealth Initiative; Dan Budnitz, Centers for Disease Control and Prevention; Betsy Chrischilles, University of Iowa; John Clarke, ECRI; David Classen, First Consulting Group; Ilene Corina, Patients United Limiting Substandards and Errors in Healthcare; Diane Cousins, U.S. Pharmacopeial Convention; Loriann De Martini, California Department of Health Services; Noel Eldridge, Veterans Health Administration; Frank Federico, Institute for Healthcare Improvement; Susan Frampton, Planetree; David Gustafson, University of Wisconsin; Ed Hammond, Duke University; Mark Hayes, Office of Senator Chuck Grassley; Carol Holquist, Food and Drug Administration; David Hunt, Centers for Medicare and Medicaid Services; Gordon Hunt, Sutter Health; John Jenkins, Food and Drug Administration; Mike Kafrissen, Johnson & Johnson; Ken Kizer, National Quality Forum; Richard Moore, Massachusetts State Senator; Bill Munier, Agency for Healthcare Research and Quality; Dianne Murphy, Food and Drug Administration; Steve Northrop, Office of Senator Chuck Grassley; Jerry xi
From page 280...
... The following individuals were important sources of information, generously giving their time and knowledge to further the committee's efforts: Michele Boisse, American Society for Clinical Pharmacology and Therapeutics; Anne Burns, American Pharmacists Association; Francis Dobscha, Advance Med; Melody Eble, Johnson & Johnson; Atheer Kaddis, Blue Cross and Blue Shield of Michigan; Lucinda Maine, American Association of Colleges of Pharmacy; Gary Merica, York Hospital; Joseph Morris, Health Care Improvement Foundation; Richard Park, IVD Technology magazine; Ken Reid, Washington Information Source Co.; Ed Staffa, National Association of Chain Drug Stores; Kasey Thompson, American Society of Health-system Pharmacists; Marissa Schlaifer, Academy of Managed Care Pharmacy; Junelle Speller, American Academy of Pediatrics; Sharon Wilson, Center for Nursing Practice; and Charles Young, Massachusetts Board of Registration in Pharmacy. The committee commissioned eight papers that provided important background information for the report, and would like to thank all the authors for their dedicated work and helpful insights: Harvey J
From page 281...
... xiii ACKNOWLEDGMENTS report To Err Is Human: Building a Safer Health System and the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century. The committee on Identifying Priority Areas for Quality Improvement produced the 2003 report Priority Areas for National Action: Transforming Health Care Quality.
From page 283...
... Contents SUMMARY 1 1 INTRODUCTION 25 PART I: UNDERSTANDING THE CAUSES AND COSTS OF MEDICATION ERRORS 43 2 OVERVIEW OF THE DRUG DEVELOPMENT, REGULATION, DISTRIBUTION, AND USE SYSTEM 50 3 MEDICATION ERRORS: INCIDENCE AND COST 105 PART II: MOVING TOWARD A PATIENT-CENTERED, INTEGRATED MEDICATION-USE SYSTEM 143 4 ACTION AGENDA TO SUPPORT CONSUMER–PROVIDER PARTNERSHIP 151 5 ACTION AGENDA FOR HEALTH CARE ORGANIZATIONS 221 6 ACTION AGENDA FOR THE PHARMACEUTICAL, MEDICAL DEVICE, AND HEALTH INFORMATION TECHNOLOGY INDUSTRIES 266 7 APPLIED RESEARCH AGENDA FOR SAFE MEDICATION USE 310 8 ACTION AGENDAS FOR OVERSIGHT, REGULATION, AND PAYMENT 328 xv
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... xvi CONTENTS APPENDIXES A BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS 349 B GLOSSARY OF TERMS AND ACRONYMS 359 C MEDICATION ERRORS: INCIDENCE RATES 367 D MEDICATION ERRORS: PREVENTION STRATEGIES 409 INDEX 447
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... Summary ABSTRACT The use of medications is ubiquitous. In any given week, more than four of five U.S.
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... accelerated existing efforts to prevent medication errors and improve the quality of health care, efforts that are just now gaining acceptance as a discipline requiring investment in individuals who specialize in error prevention and quality improvement. Against this background, at the urging of the Senate Finance Committee, the United States
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... 3 SUMMARY BOX S-1 Scope of the Study Congress, through the Medicare Modernization Act of 2003 (Section 107(c)
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... 4 PREVENTING MEDICATION ERRORS BOX S-2 Key Definitions Error: The failure of a planned action to be completed as intended (error of execu tion) or the use of a wrong plan to achieve an aim (error of planning)
From page 289...
... The committee estimates that at least 1.5 million preventable ADEs occur each year in the United States: • Hospital care -- Classen and colleagues (1997) projected 380,000 preventable ADEs occurring annually, and Bates and colleagues (1995b)
From page 290...
... 6 PREVENTING MEDICATION ERRORS care enrollees aged 65 and older. The cost in 2000 per preventable ADE was estimated at $1,983, while national annual costs were estimated at $887 million.
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... 7 SUMMARY consumers and providers (including physicians, nurses, and pharmacists) should know and act on patients' rights, providers should engage in meaningful communication about the safe and effective use of medications at multiple points in the medication-use process, and government and other participants should improve consumer-oriented written and electronic information resources.
From page 292...
... 8 PREVENTING MEDICATION ERRORS provider understanding and exercise of these rights and improve the safety and quality of medication use. Actions for Consumers For sound medication management, providers and consumers2 should maintain an up-to-date record of medications being administered, including prescription medications, over-the-counter (OTC)
From page 293...
... 9 SUMMARY BOX S-4 Consumer Actions to Enhance Medication Safety Personal/Home • Maintain a list of the prescription drugs, nonprescription drugs, and other products, such as vitamins and minerals, you are taking. • Take the list with you when you visit any medical practitioner, and have him or her review it.
From page 294...
... 10 PREVENTING MEDICATION ERRORS BOX S-5 Issues for Discussion with Patients by Providers (Physicians, Nurses, and Pharmacists) • Review the patient's medication list routinely and during care transitions.
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... 11 SUMMARY Recommendation 1: To improve the quality and safety of the medication-use process, specific measures should be instituted to strengthen patients' capacities for sound medication self management. Specifically: • Patients' rights regarding safety and quality in health care and medication use should be formalized at the state and/or federal levels and ensured at every point of care.
From page 296...
... 12 PREVENTING MEDICATION ERRORS The federal government should develop mechanisms for improving pharmacy leaflets and the quality of Internet information for consumers. Second, there is a need for additional resources beyond pharmacy leaflets and Internet information that can be provided on a national scale.
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... 13 SUMMARY • A national plan should be developed for widespread distribu tion and promotion of medication safety information. Health care provider, community-based, consumer, and government organiza tions should serve as the foundation for such efforts.
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... 14 PREVENTING MEDICATION ERRORS issues before such strategies are implemented and aggressively solving technological problems during the implementation process. Regulatory issues must also be addressed for electronic transmission of prescriptions to be practical.
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... 15 SUMMARY Reconciliation is facilitated when medication data are transmitted electronically among providers, with confirmation by the patient. Three important steps are required.
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... 16 PREVENTING MEDICATION ERRORS ingly clear that the introduction of any of these technologies requires close attention to business processes and ongoing maintenance. As noted above, studies have shown that these tools can have unintended and adverse consequences, and that avoiding these consequences requires addressing both business and cultural issues.
From page 301...
... 17 SUMMARY Risk/Benefit Information for Prescription Drugs Being able to determine whether a medication error has been made depends on knowing the correct dose of the drug for that patient at that time and whether the indication for that drug is correct in comparison with alternative approaches to treatment. Over the past several decades, however, drug evaluations have not been sufficiently comprehensive.
From page 302...
... Unit-of-use packaging -- containers that provide enough medication for a particular period, such as blister packs containing 30 individually wrapped doses -- is not widely employed in the United States but is used extensively elsewhere. This form of packaging brings important safety and usage benefits.
From page 303...
... 19 SUMMARY ments to occur, materials should be designed according to desig nated standards to meet the needs of the end user. Industry, AHRQ, the FDA, and others as appropriate (e.g., U.S.
From page 304...
... 20 PREVENTING MEDICATION ERRORS presenting safety alerts according to severity and/or clinical importance. Instead, providers are sometimes inundated with too many alerts, which can result in "alert fatigue." Third, many systems lack intelligent mechanisms for relating patient-specific data to allowable overrides, such as those associated with a particular patient and drug allergy alert or duplicate therapy request.
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... 21 SUMMARY and prevention strategies. The committee believes the nation should invest about $100 million annually in the research proposed below.
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... 22 PREVENTING MEDICATION ERRORS delivered, including legislators, regulators, accreditors, payers, and patient safety organizations.3 Recommendation 7: Oversight and regulatory organizations and payers should use legislation, regulation, accreditation, and pay ment mechanisms and the media to motivate the adoption of prac tices and technologies that can reduce medication errors, as well as to ensure that professionals have the competencies required to de liver medications safely. • Payers and purchasers should continue to motivate improve ment in the medication-use process through explicit financial incentives.
From page 307...
... 23 SUMMARY REFERENCES AHRQ (Agency for Healthcare Research and Quality)
From page 308...
... 24 PREVENTING MEDICATION ERRORS Gurwitz JH, Field TS, Judge J, Rochon P, Harrold LR, Cadoret C, Lee M, White K, LaPrino J, Mainard JF, DeFlorio M, Gavendo L, Auger J, Bates DW.


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