[VickyRN]

Another excellent resource:

How to Avoid Medication Errors

[VickyRN]

How-to Guide: Prevent Adverse Drug Events (Medication Reconciliation)
Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital. If any pre-admission medication is either not ordered or not explicitly declared to be inappropriate, the nurse or pharmacist should contact the patient’s physician. The physician should then either order the medication or formally confirm that the omission was deliberate.

How-to Guide: Prevent Harm from High-Alert Medications
High-alert (or high-hazard) medications are medications that are most likely to cause significant harm to the patient, even when used as intended. The Institute for Safe Medication Practices (ISMP) reports that, although mistakes may not be more common in the use of these medications, when errors occur the impact on the patient can be significant.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), referring to ISMP’s work, describes high-alert medications as those “that have the highest risk of causing injury when misused” (“High-Alert Medications and Patient Safety.” Joint Commission Sentinel Event Alert. November 19, 1999).

Based on reports submitted to ISMP, a review of literature, and the experience of many hospitals around the country, the list of high-alert medications includes as many as 19 categories and 14 specific medications. Although it is important to improve management of all of these medications, some of them are used more frequently and the resulting harm from this subset may be more significant.


The 5 Million Lives Campaign
A national initiative led by IHI, the 5 Million Lives Campaign aims to dramatically improve the quality of American health care by protecting patients from five million incidents of medical harm between December 2006 and December 2008. The How-to Guides associated with this Campaign are designed to share best practice knowledge on areas of focus for participating organizations. For more information and materials, go to www.ihi.org/IHI/Programs/Campaign.

[NRSKarenRN]

Institute For Safe Medication Practices Nurse Survey

Problems in Nursing Practice that Contribute to Errors

Please visit www.fc4research.com/ME2008/ to complete a brief questionnaire to help ISMP identify problems in nursing practice that contribute to errors.

The deadline for survey responses is June 30, 2008


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To report medication errors, call ISMP at 1-800-FAIL-SAF(E) or complete the form at this ISMP link: https://www.ismp.org/orderforms/reporterrortoISMP.asp. All communications are kept confidential.