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It's not too late for one more New Year's resolution

From the February 25, 1998 issue

Now that your New Year's resolutions are well underway (or even if they're not), there is still time to make one more-a New Year's resolution for your institution. Although there are many error prevention strategies that we could suggest, ISMP has chosen one to recommend as your 1998 resolution for your institution: seek and use knowledge from the outside.

Experience has shown that a medication error reported in one institution is also likely to occur in another, given enough time. Much knowledge can be gained when institutions look outside themselves to learn from the experiences of others. Unfortunately, many don't seek and use this information. Recommendations for improvement, often made by those faced with unraveling a devastating error, go unheeded by others. Some may read about medication errors experienced by other institutions with interest, but they do not use that information to make proactive changes within their own institutions. They truly do not believe that the same errors could happen within their institutions. Still others have committees that are working on tough issues and doing their best, but they have an internal focus only. Real knowledge about medication error prevention will not come from a committee with only an internal focus.

A system cannot understand itself. Quality guru Dr. W. Edwards Deming summarized this phenomenon by noting that organizations with an internal focus "can learn a lot about ice and know nothing about water." (Deming WE. The new economics. MIT Center for Advanced Engineering Study; 1993.) Knowledge from the outside is necessary and provides us with a lens to examine what we are doing, suggestions for what we might do differently, and a roadmap for improvement.

ISMP suggests that, in order to seek and use outside knowledge about medication error prevention, institutions develop a small sub-committee, ideally comprised of a nurse, pharmacist, physician, and medical librarian. The committee should follow and search both professional literature and news media routinely for descriptions of medication errors (or potentially hazardous situations) that have occurred in other institutions. Then the errors should be examined, and any recommendations made for prevention should be considered. The information should be brought to other internal committees so that error prevention strategies can be implemented-a proactive rather than a reactive approach.

Since ISMP believes that this will make a significant impact on your error prevention efforts, we want to assist you in making and keeping this resolution. For 1998, ISMP will provide you with a quarterly agenda of high priority items from the ISMP Medication Safety Alert! for discussion at your committees. Organizations can use the agenda to prompt discussion of error- prone situations, and then take the necessary action to prevent serious adverse drug events. The first quarterly agenda will be included with the April 8th newsletter.

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