Medication Safety Initiative
Medication-related errors are a major contributor to compromised safety. The Coalition has identified medication safety as a priority area, and will focus its resources on where it can be most effective: the prevention of error.
The primary goal of the Coalition’s Medication Safety Initiative (MSI) is to improve clear, unambiguous communication between prescribers, pharmacists, and consumers. The major activities are the following:
- Eliminate unsafe abbreviations (see, for example, the JCAHO recommendations).
- Eliminate the use of trailing zeroes and promote the appropriate use of leading zeroes.
- Promote the inclusion of indication or purpose on all prescriptions (written by prescribers and as dispensed by pharmacists).
- Encourage prescribers to have patients “read back and explain” scrips when written.
- Develop a common message for prescribers, pharmacists, and consumers regarding steps to enhance medication safety.
- Decrease inappropriate polypharmacy by encouraging and facilitating medication review and appropriate follow-up.
Use of New Medication Safety Guide Can Help Improve Care in Outpatient Practices
AHRQ researchers have developed an easy-to-use medication safety guide that helps outpatient physician practices incorporate safer systems for medication sample prescribing and dispensing. The guide was developed as a result of an AHRQ study that found that standards for medication safety among 31 physician practices were suboptimal and unacceptable. With this assessment tool, health care providers can now closely examine and take inventory of their current practices of medication use, error management, and safety education. Designed in a checklist format, the guide helps users rate their current medication use processes-prescribing, dispensing, administering, counseling, and monitoring-so plans for improvements can be prioritized and implemented. The guide also addresses processes in technology and safety, office environment, error management, workplace conditions, safety education, and safety perceptions. AHRQ researchers, led by Kimberly A. Galt, Pharm.D., Associate Dean of Research and Professor of Pharmacy Practice, Creighton University, Omaha, NE, plan to develop new components for the guide to address electronic prescribing and other innovations in health information technology. Select to access the self-assessment guide, Medication Safety Best Practices Guide for Ambulatory Care Use is downloadable free of charge in .pdf format.
Resources
- The Joint Commission on the Accreditation of Health Care Organizations (JCAHO)
- The Institute for Safe Medication Practices (ISMP)
See also their list of error-prone abbreviations and opinion regarding HIPAA and the inclusion of a drug’s purpose on prescriptions. - FDA’s MedWatch
- Washington State Department of Health
- Washington State Medical Association
- Massachusetts Coalition for the Prevention of Medical Errors
- FDA/ISMP's “Campaign to Eliminate Use of Error-Prone Abbreviations”
Avoiding use of unclear or misleading abbreviations is a key step in preventing medication prescribing errors, and the Joint Commission mandates avoiding specific abbreviations as one of its National Patient Safety Goals. This study analyzed Medmarx data from 2004 to 2006 to determine the prevalence and impact of errors related to abbreviations. Despite dissemination of the Joint Commission's “do not use” abbreviation list, errors involving these abbreviations occurred more than 18,000 times during the study period, although few patients were harmed as a result.
Contact us with questions, requests for information or tools and resources, or if you are interested in participating as a pilot site for interventions.
