The ISMP Ambulatory Care Action Agenda:
Learn from others’ mistakes

No news is not good news when it comes to patient safety. Each organization needs to accurately assess how susceptible its systems are to the errors that have happened in other organizations, and acknowledge that the absence of similar errors is not evidence of safety. Personal experience is a powerful teacher, but the price is too high to learn all we need to know from firsthand experiences. Learning from the mistakes of others is imperative.

A great way to utilize the ISMP Medication Safety Alert!® Community/Ambulatory Care Edition is by using the Ambulatory Care Action Agenda. Three times a year, selected items are prepared for you and your staff to stimulate discussion and collaborative action to reduce the risk of medication errors previously reported to the ISMP Medication Errors Reporting Program (MERP). The agenda topics appeared in the ISMP Medication Safety Alert! Community/Ambulatory Care Edition during the preceding 4 months. Each item includes a brief description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number to locate additional information as desired.

The action agenda is presented in a format that allows community practice sites to document their medication safety activities, which is important for internal quality improvement efforts but also important for any external accrediting or regulatory organizations. Each pharmacy practice site should convene a staff meeting to discuss each item in the Action Agenda. The staff should ask themselves, ‘Can this error occur at our site?’ If the answer is ‘yes’, the ISMP recommendations for prevention should be reviewed for applicability at that specific site. If the recommendations are germane to the practice site, the columns on the Action Agenda indicating ‘Organization Assessment’ and ‘Action required/Assignment’ should be completed and a reasonable time set for completion. The staff should reconvene in 3 months time to determine if the proposed recommendation strategies have been implemented, if they are still pertinent, and if other strategies have been offered or considered since the initial meeting.

According to the 2008 Survey of Pharmacy Law, published by the National Association of Boards of Pharmacy, at least 19 states regulate, require or recommend a Continuous Quality Improvement (CQI) program to monitor and prevent quality related events. The purpose of the CQI program is to detect, document, and assess prescription errors in order to determine the cause, develop an appropriate response, and prevent future errors. Utilization of the Action Agenda to review externally reported errors combined with review and analysis of internally reported events constitutes a feasible and effective CQI program.

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