Assessing Probability
March 11, 2019

In order to reduce medication errors, it is essential that they first be identified and reported, a key component of Root Cause Analysis. This process helps us to first identify the root cause of the error, develop a plan of action to be implemented and establish outcome measures.

Having a good reporting system is a critical component of any medication errors program. It is important to ensure that all healthcare providers are aware of the necessity to report and are not concerned about the process being punitive. Both points are vital to ensure that the program functions properly.

Another key component of an effective med errors program is to ensure that the system that is being used is, in fact, user friendly. All participants must be competent with the system and the system itself should allow users the ability to 1) complete the process in a timely fashion, 2) easily retrieve critical data,  3) generate reports, 4) analyze data to detect trends, 5) calculate med error rates, 6) determine the effectiveness of newly implemented programs and 7) easily demonstrate how the med errors program is having an impact by reducing med errors. In addition, all programs should be reasonably responsive to the user and the various type errors encountered.

There are a number of programs that are available for tracking med errors. Many are very costly and may not include all necessary components. Routinely reviewing your med errors program to ensure it meets your needs is important to ensure that med errors are being minimized. Having a program is good but having an effective program is better. And any program begins with ensuring that med events are reported when they occur. The failure to report can compromise any med errors program.

#MatthewGrissinger, BSPharm, who is the director of error reporting programs with ISMP, discusses the inexcusable error—the failure to report. Read more here: http://ow.ly/levq30jeRu9 #MedicationErrors #MedicalMalpractice #Malpractice

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