12/2/2009
Press Release
National Alert System Launches to Prevent Deadly Medication Errors
Two leading health care organizations announce today a new national alert system that helps prevent dangerous and repeated medication errors. The American Society of Health-System Pharmacists (ASHP) and the Institute for Safe Medication Practices (ISMP) are partnering to develop the National Alert Network for Serious Medication Errors (NAN).
NAN will be triggered when a seriously harmful or potentially seriously harmful error has occurred.
The alert will include a description of the error, as well as recommendations to prevent the same error in the future.
The alert network was created as a result of ASHP’s I.V. Safety Summit held in 2008. The I.V. Safety Summit brought together top experts to discuss ways to help bring an end to deadly medication errors, such as the one that seriously harmed Dennis Quaid’s infant twins.
“This rapid system of sharing information with physicians, nurses, pharmacists and others in health care sets this alert system apart from previous efforts,” said Henri R. Manasse, Jr., ASHP Executive Vice President and CEO. “It is heartbreaking and frustrating to see the same mistakes happen again and again. This alert system is a significant and imperative step – creating more transparency and breaking the chronic cycle of medication errors.”
ASHP will disseminate the email alerts to its extensive network of nearly 35,000 health-system pharmacists, as well as other engaged health care practitioners, including physicians and nurses. When an alert is sent out, recipients can use the recommendations provided to take immediate action to make sure the error is not repeated at their facility. With broad reach this system can help prevent a similar error from occurring again anywhere in the country.
The event-specific information contained in the alerts will be obtained through a variety of channels, including voluntary reporting and news reports. When the information is not obtained through public resources, the alerts will not identify the hospital, patient or health care providers involved in the error. The alerts will be archived and available to the public on the ASHP web site at www.ashp.org/iv-summit.
“We know that health care professionals are overwhelmed with alerts now. This network activates when the most dangerous types of errors occur,” said Mike Cohen, ISMP CEO. “The point is for the alerts to receive immediate, urgent attention from all health care providers. Our goal—to see less than six alerts per year.”
About ASHP
For more than 60 years, ASHP has helped pharmacists who practice in hospitals and health systems improve medication use and enhance patient safety. The Society's 35,000 members include pharmacists and pharmacy technicians who practice in inpatient, outpatient, home-care, and long-term-care settings, as well as pharmacy students. For more information about the wide array of ASHP activities and the many ways in which pharmacists help people make the best use of medicines, visit ASHP's Web site, www.ashp.org, or its consumer Web site, www.SafeMedication.com.
About ISMP
The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization that works closely with healthcare practitioners and institutions, regulatory agencies, consumers, and professional organizations to provide education about medication errors and their prevention. ISMP represents more than 35 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process. ISMP is a federally certified patient safety organization (PSO), providing healthcare practitioners and organizations with the highest level of legal protection and confidentiality for patient safety data and error reports they submit to the Institute. For more information on ISMP, or its medication safety alert newsletters and other tools for healthcare professionals and consumers, visit www.ismp.org
NAN will be triggered when a seriously harmful or potentially seriously harmful error has occurred.
The alert will include a description of the error, as well as recommendations to prevent the same error in the future.
The alert network was created as a result of ASHP’s I.V. Safety Summit held in 2008. The I.V. Safety Summit brought together top experts to discuss ways to help bring an end to deadly medication errors, such as the one that seriously harmed Dennis Quaid’s infant twins.
“This rapid system of sharing information with physicians, nurses, pharmacists and others in health care sets this alert system apart from previous efforts,” said Henri R. Manasse, Jr., ASHP Executive Vice President and CEO. “It is heartbreaking and frustrating to see the same mistakes happen again and again. This alert system is a significant and imperative step – creating more transparency and breaking the chronic cycle of medication errors.”
ASHP will disseminate the email alerts to its extensive network of nearly 35,000 health-system pharmacists, as well as other engaged health care practitioners, including physicians and nurses. When an alert is sent out, recipients can use the recommendations provided to take immediate action to make sure the error is not repeated at their facility. With broad reach this system can help prevent a similar error from occurring again anywhere in the country.
The event-specific information contained in the alerts will be obtained through a variety of channels, including voluntary reporting and news reports. When the information is not obtained through public resources, the alerts will not identify the hospital, patient or health care providers involved in the error. The alerts will be archived and available to the public on the ASHP web site at www.ashp.org/iv-summit.
“We know that health care professionals are overwhelmed with alerts now. This network activates when the most dangerous types of errors occur,” said Mike Cohen, ISMP CEO. “The point is for the alerts to receive immediate, urgent attention from all health care providers. Our goal—to see less than six alerts per year.”
About ASHP
For more than 60 years, ASHP has helped pharmacists who practice in hospitals and health systems improve medication use and enhance patient safety. The Society's 35,000 members include pharmacists and pharmacy technicians who practice in inpatient, outpatient, home-care, and long-term-care settings, as well as pharmacy students. For more information about the wide array of ASHP activities and the many ways in which pharmacists help people make the best use of medicines, visit ASHP's Web site, www.ashp.org, or its consumer Web site, www.SafeMedication.com.
About ISMP
The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization that works closely with healthcare practitioners and institutions, regulatory agencies, consumers, and professional organizations to provide education about medication errors and their prevention. ISMP represents more than 35 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process. ISMP is a federally certified patient safety organization (PSO), providing healthcare practitioners and organizations with the highest level of legal protection and confidentiality for patient safety data and error reports they submit to the Institute. For more information on ISMP, or its medication safety alert newsletters and other tools for healthcare professionals and consumers, visit www.ismp.org
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