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September 2004 Article: The Phoenix Network Medication Error Prevention
Program (MEPP): Helping to Protect You! |
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In November of 1999, the Institute of Medicine published their report “To
Err Is Human: Building a Safer Health System” stating publicly that
medication errors were unacceptably high throughout the entire health care
system. Since then, the Phoenix Area Medication Error Prevention Program
(MEPP) has been created to address medication errors that may be occurring
within the Phoenix Area Network. The MEPP is a network-wide multidisciplinary
effort involving everyone in the medication management process, including
but not limited to those who prescribe, administer, dispense, or who take
prescription medications handled by IHS or participating tribal facilities.
The program collects medication error and “near miss” data from
each service unit, hospital, and primary care clinic in the Phoenix Area,
collectively called the Phoenix Area Network, and the Tucson Area hospitals
and clinics. A “near miss” is a situation where a health care
professional believes that there is potential for a medication error. These
data are then aggregated and analyzed at the service unit and/or facility
level, at the Network level by the Medication Error Prevention Subcommittee
(MEPSC) of the Network Quality Council, and at the IHS Headquarters’ level.
Results, recommendations and suggestions for improvement are disseminated
back to the service unit facilities through the Network Quality Managers.
Service units and or facilities take action at the local level based on the
results of their local analysis. Action is taken at the Network level in
those cases involving network-wide applications, policies, procedures, computer
systems, or other shared systems. All program information is reported to
IHS Headquarters, who subsequently reports the results to the Department
of Health and Human Services.
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Why Report?
The basic premise to medication error reporting is that health care
professionals in the course of business do their very best to perform day-to-day
duties including the prescribing, administering, and dispensing of medications
in the most accurate and efficient way possible. But, we are only human,
and humans make mistakes. Therefore, the health care systems that we have
in place should provide additional checks at those points in health care
delivery most prone to the effects of human error. These checks might come
in the form of automated double checks provided through the use of bar
coding, or automation assisted checks like those provided in the Health
Care Summary allowing professionals to see all of the patient’s medications
side by side. Checks might also come as multiple human checks as when a
nurse asks another nurse to double check his or her medication calculations,
or the pharmacy practice of checking a prescription three times. Health
care systems are quite complex, and are getting more complex all of the
time. A busy facility may have anywhere from a few to a hundred health
care professionals providing care for tens to hundreds of patients a day.
As health care gets more complex, the chance for system gaps allowing medication
errors increases. Therefore medication error data collection and analysis
is a must to prevent as many future medication errors as possible. Medication
error prevention is of such a high priority in the IHS that Headquarters
has implemented a medication error prevention standard under the Government
Performance and Results Act (GPRA), requiring medication error reporting.
Medication error reporting has been a high priority in the Phoenix Network
since the MEPP program was implemented in November of 2001. The Surgeon
General has mandated medication error reporting in all Federal facilities.
JCAHO has mandated a medication error prevention program in every accredited
institution.
Who Should Report?
Anyone who discovers a medication error may report. Physicians, nurses,
and pharmacists are professionally obligated and required by the Network
to report. Patients and families are encouraged to be sure that they understand
what their medications are for, how they are supposed to take their medications,
what to expect from their medications, and the reasons for any changes.
Patients and families should report anything that they do not understand
to their physician, pharmacist, or nurse.
Who Has Been Reporting?
Based on submitted Network medication error reports, pharmacists have
discovered and reported nearly one-half (1/2) of all of the Network medication
errors. Nurses have discovered and reported an additional one-third (1/3)
of medication errors. Patients and family members have discovered and reported
one-eighth (1/8) of the medication errors, and physicians one-twentieth
(1/20) of the errors.
What Do I Report?
According to the National Coordinating Council for Medication Error
Reporting and Prevention:
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A medication error is any preventable event that may cause or lead
to inappropriate medication use or patient harm while the medication is in
the control of the health care professional, patient or consumer. Such events
may be related to professional practice, health care products, procedures
and systems, including prescribing; order communications; product labeling,
packaging and nomenclature; compounding; dispensing; distribution; administration;
education; monitoring; and use.” In short, if you see anything that
you do not understand regarding your medications, report it.
If I report a medication error will anyone get into trouble?
No. In fact, Ms. Mary Lou Stanton, the Area Deputy Director, has ordered
that no punitive action be taken on the basis of reported medication errors.
Most often, a medication error does not reflect the skill level or thoroughness
given by the health care professional, but reflects inadequate double checks
in areas that are problem prone. This initiative is an effort to make sure
we have the proper double checks in place, and if we do not, to get them
in place.
This initiative has been going on for nearly two years. What good has come
of it?
The first Medication Error Prevention Subcommittee (MEPSC) meeting occurred
in September of 2001. Since that time, in an effort to reduce patient risk
and prevent future medication errors, the MEPSC has:
- Created a medication error reduction strategy and data collection
process for the Network.
- Standardized the definition of “Medication Error” to facilitate
error and “near miss” reporting.
- Designated a Medication Error Prevention Coordinator for each Network
facility.
- Created a more open, less punitive system for reporting medication
errors and “near misses”.
- Identified where and how reporting could be improved.
- Analyzed error and “near miss” data to date for participating
facilities, and the entire Network.
- Shared best practices and “lessons learned” throughout the
Network.
- Eliminated the use of high risk abbreviations in 91% of the areas
where patient care is provided, so far.
- Recommended that each facility require two types of patient identification
before prescribing, administering, or dispensing medications to insure that
medications get to the correct patient.
- Recommended that each facility evaluate local medication systems in an
effort to decrease distractions, more effectively deploy staff, more thoroughly
orient staff, and to maximize the use of contractors.
- Recommended that each facility develop on-going proactive measures, and
continue open discussions regarding how to decrease and or eliminate medication
errors.
- Recommended the elimination of the practice of treating patients by using
preprinted forms absent of the complete medical record.
So that is where we are in the development of the Network Medication Error
Prevention Program. Please remember that you, as the patient or concerned
family member, are one of the most important parts of our medication error
prevention strategy. Please help us to help you by reporting anything that
you do not understand about your medications to one of our physicians, pharmacists,
or nurses.
Respectfully submitted by:
Captain Chris Watson, R.Ph., MPH, PAIHS Pharmacy Officer
Sheila Warren, RN, MPH, CPHQ, PAIHS Quality Management Nurse Consultant
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Phoenix Area Indian Health Service
Two Renaissance Square • 40 North Central Avenue • Phoenix, AZ 85004-4424
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