Medication error council promotes
error prevention recommendations
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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
|
|
|
