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Medication error council promotes error prevention recommendations


From the September 11, 1996 issue

The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) has released a document recommending steps needed to correct error-prone aspects of prescription writing. It includes a recommendation that prescription communications include the medication's purpose as a way to help prevent medication dispensing errors. The document also addresses illegibility of prescriptions and medication orders and contains a list of dangerous abbreviations, developed in cooperation with ISMP, that should never be used in prescription writing. While the ideas will be familiar to many health care practitioners, the NCCMERP action adds a new level of importance since the group is represented by major professional organizations and regulatory authorities such as USP, FDA, AMA, APhA, ANA, AHA, PhRMA, JC and NABP.

In a second action, NCCMERP also began promoting a new medication error categorization index. The index was designed to help health care professionals track medication errors consistently and systematically by establishing severity levels to provide a focus for improvement efforts. The new index, based on one designed by Hartwig et al (Hartwig SC et al. A severity-indexed, incident-report based medication-error reporting program. Am J Hosp Pharm. 1991;48:2611-6) appears below.

Medication Error Index for Categorizing Errors

TYPE OF ERROR/ CATEGORY

RESULT

NO ERROR

Category A

Circumstances or events that have the capacity to cause error

ERROR, NO HARM

Category B

An error occurred but the medication did not reach the patient

Category C

An error occurred that reached the patient but did not cause patient harm

Category D

An error occurred that resulted in the need for increased patient monitoring but no patient harm

ERROR, HARM

Category E

An error occurred that resulted in the need for treatment or intervention and caused temporary patient harm

Category F

An error occurred that resulted in initial or prolonged hospitalization and caused temporary patient harm

Category G

An error occurred that resulted in permanent patient harm

Category H

An error occurred that resulted in a near-death event (e.g., anaphylaxis, cardiac arrest)

ERROR, DEATH

Category I

An error occurred that resulted in patient death

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