Medication Prescribing Error Reporting and Prevention Program: A 14-Year Experience

Timothy S. Lesar, PharmD

Disclosures

August 14, 2000

In This Article

Introduction

The recent Institute of Medicine (IOM) report on medical errors has focused attention on the need for improved safety of our medical-care delivery system.[1] Mistakes involving medications are a major, and often preventable, cause of adverse drug events (ADE). Errors and deficiencies in the prescribing step of the medication-use process are common and account for a large proportion of the preventable ADE in hospitals. The frequency and nature of prescribing errors have been well described.[1,2,3,4,5,6,7,8,9,10] The IOM,[1] as well as other organizations,[11,12,13] recommend the implementation of effective medical-error reporting systems. Improved error reporting underlies, and supports, understanding of mistakes and their causes, contributors, and potential solutions. A comprehensive reporting program for errors in prescribing can be implemented relatively simply in most healthcare environments as prescriptions/orders are usually evaluated and carried out (prepared, dispensed, administered) by a second professional (usually a nurse or pharmacist) who is considered jointly responsible for ensuring patient safety. As such, the safety processes for reducing patient risk for ADE due to prescribing errors are already in place. Optimization of the effectiveness of these safety processes is enhanced by systematic collection and use of prescribing error detection and prevention data. This article describes the 14-year experience with a continuous medication prescribing error detection, prevention, documentation, analysis, and application program of the Albany Medical Center (AMC) in Albany, New York. The objective of this article is to describe the value of an ongoing process for the documentation, evaluation, and application of information about medication errors.

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