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New millennium brings great promise and support for reducing medication errors



From the December 15, 1999 issue

Two weeks ago, the Institute of Medicine (IOM) Quality of Health Care in America Committee released its landmark report, "To Err is Human: Building a Safer Health System," which details a national agenda to reduce medical errors. Last week, the American Hospital Association (AHA) and ISMP announced the formation of a long-term partnership to provide hospitals with the latest information and best practices being used across the US to improve medication safety. As a first step, AHA sent a Quality Advisory to all US hospital CEOs that detailed successful practices for improving medication safety (the Quality Advisory is available on our web site at www.ismp.org). Along with other invited guests and US cabinet members, the President of AHA, Dick Davidson, and the President of ISMP, Michael Cohen, met with President Clinton as he announced new executive actions to enhance the safety of federal employees enrolled in over 300 health care plans. Later, the President publicly praised the AHA-ISMP partnership at a Rose Garden press conference. AHA and ISMP pledged their commitment to work closely with the task force directed to analyze the IOM report and suggest ways to implement the recommendations.

The IOM committee recommendations begin with the creation of a Center for Patient Safety to lay the groundwork for national leadership. The Center would be charged with setting national goals, understanding errors, developing a research agenda, and funding Centers of Excellence to evaluate methods for identifying and preventing errors and communicating safety activities. The committee suggests a role for both mandatory and voluntary reporting systems. A national mandatory reporting system would be established and facilities (hospitals initially) would be required to report serious or fatal adverse events to their state governments. The Center would evaluate state reporting programs, identify the best practices for implementation, and assess the overall impact of state reporting programs. The committee also recommends that the Center promote greater participation in external voluntary reporting systems by disseminating information on the programs, convening sponsors and users to identify improvements, and funding pilot projects. The committee stresses both reporting and adequate resources for analysis and response to critical issues. To reduce legal obstacles, it's recommended that Congress pass legislation to extend peer review protections to patient safety and quality improvement data used internally or shared with programs like the USP-ISMP Medication Error Reporting Program for purposes of improving safety and quality. However, to avoid compromising patients' legal rights, the committee suggests that errors resulting in serious patient harm should not be protected from public disclosure.

To focus performance standards and expectations on safety, it's recommended that regulators and accreditors strengthen their requirements for meaningful patient safety programs with defined executive responsibility. Likewise, private and public purchasers should provide incentives to organizations that demonstrate ongoing improvement in patient safety. The committee recommends that licensing bodies periodically re-examine practitioner competence and knowledge of safety practices. It's also suggested that professional societies establish permanent, collaborative, safety committees that disseminate information regularly and develop safety curricula for practitioner training and certification. Recommendations are included for FDA to increase drug safety through labeling and packaging standards, required testing of proposed drug names, and timely and appropriate response to problems identified through post-marketing surveillance. The report suggests that organizations establish non-punitive error reporting and analysis systems, incorporate safety principles such as standardization and simplification, and train practitioners to function as an interdisciplinary team. Finally, the committee recommends that organizations implement proven medication safety practices that have been developed and published by professional and collaborative organizations, such as ISMP.

When answering questions about the IOM report at the Rose Garden press conference last week, President Clinton told reporters that, "Ensuring patient safety is not about fixing blame. It's about fixing problems in an increasingly complex system." While reporters focused on the distressing state of medical error described in the report, the President responded by saying, "I think we should look at this as a very positive event in the progress of American health care.This is a good day for America, not only because of this report, but because of the response to this report." ISMP and AHA look forward to the new millennium as we work with you to reduce errors.

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