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Wisconsin Coalition Recommends Steps for Reducing Medication Errors

Nancy Tarleton Landis

A statewide coalition of health care, consumer, and business groups in Wisconsin has endorsed a set of recommendations for improving the safety of medication use and reducing errors. Leading the development of the coalition was the Pharmacy Society of Wisconsin (PSW), ASHP's state affiliate, along with the state medical society. The state hospital association joined in, followed by another dozen organizations that make up the coalition's core.

The patient safety coalition made medication errors in organized health care settings its first priority, but it noted that steps are needed to reduce errors in outpatient settings like physician offices and community pharmacies as well. The coalition said its 10 recommendations (see box below) "warrant immediate attention by providers, purchasers, and consumers of health care in Wisconsin."

Medication Safety Recommendations for Wisconsin Health Care Providers

For further information about the recommendations, go to

  1. Hospitals, extended care facilities, nursing homes and other health care facilities need to provide 24-hour pharmacy coverage either on-site or on-call (by telephone access to a staff pharmacist or contracted through a community pharmacist).
  2. Hospitals, community pharmacies, ambulatory clinics, and any other health care facilities that dispense medication should utilize available computer software to provide clinical screening to maximize patient safety in the dispensing of all prescription medications.
  3. Hospitals and other appropriate health care facilities should conduct an evaluation of an integrated computerized prescriber order-entry (CPOE) system with clinical decision support for medications and other ordered services by January 1, 2002, with implementation by January 1, 2004.
  4. Hospitals, extended care facilities, nursing homes and other appropriate health care facilities responsible for the administration of medications to patients should implement an oral and inhalant unit dose distribution system for all nonemergency medications administered within the facility by January 1, 2002.
  5. Hospitals and ambulatory health care centers should utilize a pharmacy-based and pharmacist-managed process for the preparation of intravenous admixture solutions.
  6. Pharmacies and physicians should include the generic name on the label of prescription medications dispensed to patients.
  7. Hospitals and other appropriate health care facilities should investigate and evaluate the use of bar-coding systems for the packaging and administration of medications by January 1, 2002.
  8. Hospitals and other appropriate health care facilities should prepare and maintain written policies and procedures for the use of select high-risk medications within the facility.
  9. Prescribers should institute actions to eliminate the use of symbols and phrases that are commonly misinterpreted by pharmacists and other health care providers.
  10. Prescribers and pharmacists should include the intended use on all prescription orders and prescription drug labels and packages for consumers.

The recommendations were unveiled at a November 2000 event that served as both an educational conference and a news conference, said pharmacist Christopher J. Decker, executive vice president of PSW. "Most in attendance were health care providers or health care administrators, but we had some policymakers, several legislators, and the press," he said. Front-page stories in Milwaukee and Madison newspapers, plus television coverage, resulted.

The board of directors of each key participant in the coalition—including PSW, the medical society, the hospital association, the state's largest business organization (Wisconsin Manufacturers & Commerce), and a health care purchasing cooperative representing employers—endorsed the recommendations "as a first step in improving medication safety," Decker said. Each organization is promoting the recommendations to its membership. For example, PSW published the recommendations and an update on the coalition's work in its bimonthly journal.

While the coalition's efforts stemmed mainly from the 1999 Institute of Medicine report on medical error, Decker said another driving factor was interest on the part of state legislators in setting policy on medical errors and medical error reporting. "That's what has driven a lot of the cohesion—that most of our organizations are resistant to state legislation that hasn't been well thought through," he said. "We're interested in seeing if we can't bring about some marketplace activity and professional activity in lieu of legislative activity, at least until there is a greater degree of comfort among the involved parties about what that legislative activity would be. We think it's premature at this point—that there's not an apparent legislative remedy to this growing concern."

Legislators attending the November 2000 conference were complimentary of the coalition's efforts and enthusiastic about the groups that were working together on patient safety, said Decker. What really caught the legislators' attention, he said, was participation of both Wisconsin Manufacturers & Commerce and the teachers' union—two groups that are nearly always on opposite sides of public policy issues. The legislators were pleased with the coalition's work, he said, because "they admitted feeling public pressure to do something on patient safety but not knowing what."

To ensure an ongoing push for improving health care quality and patient safety, core participants in the coalition are creating a state center. PSW and other organizations have committed funding for the center, Decker said, and coalition members hope to eventually secure state funds for the center's work. One area for exploration by the center is changing the system of payment for health care from simply paying providers for services to rewarding them for quality, he said.

How far do health care providers have to go to fulfill the coalition's recommendations? That varies, said Decker. The coalition expects to get a reading on the status of acute care organizations when data become available from a survey by the state hospital association and the Institute for Safe Medication Practices.