Comparison of Institute of Medicine (IoM) Strategies Regarding Medication Practices and Recommendations from Other Organizations:

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IoM Strategy American Society of Health-System Pharmacists National Coordinating Council for Medication Error Reporting and Prevention Institute for Healthcare Improvement National Patient Safety Partnership Massachusetts Coalition for the Prevention of Medical Errors Implement standard processes for medication doses, dose timing, and dose scales in a given patient care unit.     Reduce reliance on memory; simplify; standardize. Standardize drug packaging, labeling, storage.   Standardize prescription writing and prescribing rules.   All prescription orders should be written using the metric system except for therapies that use standard units. The term "units" should be spelled out. A leading zero should always precede a decimal expression of less than one. Prescribers should avoid use of abbreviations. Differentiate; eliminate look-alikes and sound-alikes. Avoid abbreviations.   Limit the number of different kinds of common equipment.           Implement physician order entry. Establish processes in which prescribers enter medication orders directly into computer systems. Prescribers should move to a direct, computerized order entry system. Decrease multiple entry. Computerize drug order entry. Implement computerized prescriber order entry systems when technically and financially feasible in light of a hospital's existing resources and technological development. Use pharmaceutical software.         Encourage pharmacy system software vendors to incorporate an adequate set of checks into computerized hospital pharmacy systems. Implement unit dosing. Use unit dose medication distribution and pharmacy-based intravenous medication admixture systems. The medication order should include drug name, exact metric weight or concentration, and dosage form.   Use "unit dose" drug systems (packaged and labeled in standard patient doses). Maintain unit-dose distribution systems (either manufacturer prepared or repackaged by pharmacy) for all non-emergency medications. Central pharmacy should supply high-risk intravenous medications.       Use pharmacy-based IV and drug mixing programs Institute pharmacy-based IV admixture systems. Use special procedure and written protocols for the use of high-risk medications.     Use protocols and checklists wisely. Limit access to high hazard drugs and use protocols for high hazard drugs. Develop special procedures for high-risk drugs using a multi-disciplinary approach, including written guidelines, checklists, pre-printed orders, double-checks, special packaging, special labeling, and education. Do not store concentrated solutions of hazardous medications on patient care units.         Remove concentrated potassium (KCl) vials from nursing units and patient care areas. Stock only diluted premixed IV solutions on units. Ensure the availability of pharmaceutical decision support. All medication orders before a first dose should be routinely reviewed by a pharmacist and all staff should seek resolution whenever there is a question of safety.       Have a pharmacist available on-call after hours of pharmacy operation. Include a pharmacist during rounds of patient care units. Assign pharmacists to work in patient care areas in direct collaboration with prescribers and those administering medications.       Information on new drugs, infrequently used drugs, and on-formulary drugs should be made easily accessible to clinicians prior to ordering, dispensing, and administering medications. Made relevant patient information available at the point of patient care. Evaluate the use of machine-readable coding (e.g., bar coding) in their medication-use processes. Prescribers should include the age and when appropriate, the weight of the patient, on the prescription or medication order. Improve access to information. Put allergies and medications on patient records. Require machine-readable labeling (bar coding). Consider the use of machine-readable coding (i.e. bar coding) in the medication administration process. Encourage the use of computer-generated or electronic medication administration records (MAR). Adopt a system-oriented approach to medication error reduction. Approach medication errors as system failures and seek system solutions to preventing them.   Increase feedback; train for teamwork; drive out fear; obtain leadership commitment; improve direct communication.   Adopt a systems-oriented approach to medication error reduction; promote a non-punitive atmosphere for reporting of errors which values the sharing of information. Improve patient's knowledge about their treatment.   Prescription orders should include a brief notation of purpose unless considered inappropriate. Prescribers should not use vague instructions such as "Take as directed" as the sole direction for use. Improve access to information. Educate patients. Patients should tell physicians about all medications they are taking and ask for information in terms they understand before accepting medications. Educate patients in the hospital, at discharge, and in ambulatory settings about the safe and accurate use of their medications.   Develop better systems for monitoring and reporting adverse drug events.   Organize the work environment for safety.

 

Source: Kohn LT, Corrigan JM, Donaldson MS (Editors), To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000. pp. 184-189.

Appendix B

Recommendations from the Institute of Medicine (IoM) Report, To Err is Human

The recommendations outlined in the IoM report fall into four general categories:

1. Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety

2. Identifying and learning from errors through immediate and strong mandatory reporting efforts, as well as the encouragement of voluntary efforts, both with the aim of making sure the system continues to be made safer for patients

3. Raising standards and expectations for improvements in safety through the actions of oversight organizations, group purchasers, and professional groups

4. Creating safety systems inside health care organizations through the implementation of safe practices at the delivery level. This level is the ultimate target of all recommendations

Recommendations:

Leadership and Knowledge

 Congress should create a Center for Patient Safety within the Agency for Healthcare Research and Quality. This center should:

• set the national goals for patient safety, track progress in meeting these goals, and issue an annual report to the President and Congress on patient safety.
• develop knowledge and understanding of errors in health care by developing a research agenda, funding Centers for Excellence, evaluating methods for identifying and preventing errors, and funding dissemination and communication activities to improve patient safety.

Identifying and Learning from Errors

 A nationwide mandatory reporting system should be established that provides for the collection of standardized information by state governments about adverse events that result in death or serious harm. Reporting should initially be required of hospitals and eventually be required of other institutional and ambulatory care delivery settings. Congress should

• designate the National Forum for Health Care Quality Measurement and Reporting as the entity responsible for promulgating and maintaining a core set of reporting standards to be used by states, including a nomenclature and taxonomy for reporting.
   
• require all health care organizations to report standardized information on a defined list of adverse events.
   
• provide funds and technical expertise for state governments to establish or adapt their current error reporting systems to collect the standardized information, analyze it and conduct follow-up action as needed with health care organizations. Should a state choose not to implement the mandatory reporting system, the Department of Health and Human Services should be designated as the responsible entity.
   
• designate the Center for Patient Safety to:
   

(1) convene states to share information and expertise, and to evaluate alternative approaches taken for implementing reporting programs, identify best practices for implementation, and assess the impact of state programs

(2) receive and analyze aggregate reports from states to identify persistent safety issues that require more intensive analysis and/or a broader-based response (e.g., designing prototype systems or requesting a response by agencies, manufacturers or others).

 The development of voluntary reporting efforts should be encouraged. The Center for Patient Safety should:

• describe and disseminate information on external voluntary reporting programs to encourage greater participation in them and track the development of new reporting systems as they form.
   
• convene sponsors and users of external reporting systems to evaluate what works and what does not work well in the programs, and ways to make them more effective.
   
• periodically assess whether additional efforts are needed to address gaps in information to improve patient safety and to encourage health care organizations to participate in voluntary reporting programs.
   
• fund and evaluate pilot projects for reporting systems, both within individual health care organizations and collaborative efforts among health care organizations.

 Congress should pass legislation to extend peer review protections to data related to patient safety and quality improvement that are collected and analyzed by health care organizations for internal use or shared with others solely for purposes of improving safety and quality.

 Performance standards and expectations for health care organizations should focus greater attention on patient safety.

• Regulators and accreditors should require health care organizations to implement meaningful patient safety programs with defined executive responsibility.
   
• Public and private purchasers should provide incentives to health care organizations to demonstrate continuous improvement in patient safety.

 Performance standards and expectations for health professionals should focus greater attention on patient safety.

• Health professional licensing bodies should:
   

(1) implement periodic re-examinations and re-licensing of doctors, nurses, and other key providers, based on both competence and knowledge of safety practices; and

(2) work with certifying and credentialing organizations to develop more effective methods to identify unsafe providers and take action.
 

• Professional societies should make a visible commitment to patient safety by establishing a permanent committee dedicated to safety improvement. This committee should:
   

(1) develop a curriculum on patient safety and encourage its adoption into training and certification requirements.

(2) disseminate information on patient safety to members through special sessions at annual conferences, journal articles and editorials, newsletters, publications and websites on a regular basis;

(3) recognize patient safety considerations in practice guidelines and in standards related to the introduction and diffusion of new technologies, therapies, and drugs;

(4) work with the Center for Patient Safety to develop community-based, collaborative initiatives for error reporting and analysis and implementation of patient safety improvements; and

(5) collaborate with other professional societies and disciplines in a national summit on the professional's role in patient safety.

 The Food and Drug Administration (FDA) should increase attention to the safe use of drugs in both pre- and post-marketing processes through the following actions:

• develop and enforce standards for the design of drug packaging and labeling that will maximize safety in use;
   
• require pharmaceutical companies to test (using FDA-approved methods) proposed drug names to identify and remedy potential sound-alike and look-alike confusion with existing drug names; and
   
• work with physicians, pharmacists, consumers, and others to establish appropriate responses to problems identified through post-marketing surveillance, especially for concerns that are perceived to require immediate response to protect the safety of patients.

 Health care organizations and the professionals affiliated with them should make continually improved patient safety a declared and serious aim by establishing patient safety programs with defined executive responsibility. Patient safety programs should:

• provide strong, clear and visible attention to safety;
   
• implement non-punitive systems for reporting and analyzing errors within their organizations;
   
• incorporate well-understood safety principles, such as standardizing and simplifying equipment, supplies, and processes; and
   
• establish interdisciplinary team training programs for providers that incorporate proven methods of team training, such as simulation.

 Health care organizations should implement proven medication safety practices.

 

      

 

Appendix A                             Return to the Beginning