Medication Event Reporting: An Important Tool in the Medication Safety Toolbox

Tuesday, August 30, 2016 12:12:54 PM

A recent ASHP NewsLink included a reminder (below) that medication errors may be reported to ISMP and adverse drug reactions to the FDA.  There is a link to their Patient Safety Resource page that directs users to these sites.  Additionally, they posted resources that help stratify severity and whether an event is preventable or not (error versus ADR).  Most preventable events (errors) do not cause harm, but some do or have the potential to have an adverse effect on the patient. 

What can hospital pharmacists do to reduce the risk of errors at our sites?  Information about an event at one facility can be useful to everyone.  If a preventable medication-related event occurs that potentially could or actually does cause harm, ISMP wants to know about it; they may in turn include information in their Quarterly Action Agenda that is distributed to subscribers. Health systems should also strive to collect and share information on events that occur at their hospitals. In both cases, hearing about specific issues can help everyone examine processes, evaluate contributing factors, and propose possible solutions. We can’t help if we don’t know about these events.  The information gathered is used by ISMP in their mission to promote medication safety on a national level, and can be monitored internally by health systems for evaluation of potential solutions.  Ultimately, the important information provided will elevate a system as a learning organization and could potentially save a life by preventing an event at another facility in the future.

ASHP Reminds Pharmacy Personnel to Report Medication Errors

Pharmacy personnel can report medication and vaccine errors and hazards to the Institute for Safe Medication Practices, which forwards reports in confidence to FDA and, when appropriate, product vendors. The National Coordinating Council for Medication Error Reporting and Prevention's Index for Categorizing Medication Errors Algorithm and the algorithm for determining whether an adverse drug event is preventable or nonpreventable may be helpful in completing reports on medication errors.