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ASHP Strongly Supports Thrust of Major New Report on Preventing Medical Error

The American Society of Health-System Pharmacists (ASHP) endorses the findings of a report on preventing medical errors released November 29 by the Institute of Medicine (IOM) of the National Academies. ASHP Executive Vice President and Chief Executive Officer Henri R. Manasse, Jr., Ph.D., Sc.D, said the strategies recommended within the report are a critical step in unifying efforts to reduce and eliminate medical error.

“We applaud the analysis and recommendations in this report. It is clear that the numerous well-intentioned efforts currently focused on this problem are not enough and that a comprehensive, well-coordinated national initiative is needed,” he said, adding, “ASHP looks forward to helping define and establish a national commitment to resolving this issue.” 

“To Err is Human: Building a Safer Health System” was based on a study by IOM’s Committee on Quality of Health Care in America. ASHP provided the Institute with background information for the report, including a summary of the efforts by health-system pharmacists over the years to reduce the incidence of medication errors. The committee, composed of many of the nation’s leading experts in medical error prevention, calls for: 

  • The creation of a National Center for Patient Safety within the federal Agency for Health Care Policy and Research,    
  • Federal legislation to establish mandatory and voluntary reporting systems,    
  • Payer and regulatory incentives to improve safety practices, and    
  • Development of a “culture of safety” within health care organizations.

ASHP’s longstanding interest in this issue is focused on preventing medication errors. Many of the IOM’s recommendations appear to be consistent with advice ASHP has issued over the years, including that hospitals should implement computerized order entry for medications to (1) avoid the problems associated with interpreting handwriting and (2) permit computer checks on dosages and harmful interactions before medicines are given to patients. 

Further, both ASHP and IOM recognize that medication errors often are caused by flaws in medication-use systems and that effective solutions to the problem will require multiorganizational and interdisciplinary approaches. 

Recently, ASHP launched an initiative, in partnership with the ASHP Research and Education Foundation, to develop an ideal medication-use system for hospitals. Patricia Lee, M.S., a senior pharmacy practice leader who has expertise in automated medication-handling systems, has been appointed ASHP Practitioner-in-Residence and is laying the groundwork for this project. 

Apropos to the IOM’s recommendations on reporting medical errors, the ASHP Board of Directors approved the following interim policy (subject to ratification by the ASHP House of Delegates) earlier this month: 

“To collaborate with other health care providers, professions, and other stakeholders to advocate and support federal legislative and regulatory initiatives that provide liability protection for the reporting and of actual and potential medication errors by individuals and health care providers; further,

To seek federal liability protection for medication-error reporting that is similar in concept to that which applies to reporting safety incidents and accidents in the aviation industry.”

ASHP is the 30,000-member national professional association that represents pharmacists who practice in hospitals, health maintenance organizations, long-term-care facilities, home care, and other components of health care systems. ASHP believes that the mission of pharmacists is to help people make the best use of medications. Assisting pharmacists in fulfilling this mission is ASHP’s primary objective. The Society has extensive publishing and educational programs designed to help members improve their delivery of pharmaceutical care, and it is a national accrediting organization for pharmacy residency and pharmacy technician training programs.