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National Summit on Medical Errors and Patient Safety Research
U.S. PharmacopeiaAdditional Statement, Submitted by Diane Cousins, RPh, Vice President Practitioner and Product Experience, U.S. Pharmacopeia, Rockville, MD The first National Summit on Medical Errors and Patient Safety Research was held on September 11, 2000, in Washington, DC. Sponsored by the Quality Interagency Coordination Task Force (QuIC), the Summit’s goal was to review the information needs of individuals involved in reducing medical errors and improving patient safety. More importantly, the summit set a coordinated and usable research agenda for the future to answer these identified needs. Selected applicants testified at the summit as members of the witness panels. The remainder of the applicants were invited to submit written comments for consideration by the steering committee. One of these statements follows. Disclaimer and Copyright Statements Key Points USP and the Center for Performance Sciences has established a Strategic Research Partnership with over 15 hospitals across the country to begin developing a standardized data base to support the identification and establishment of best practices for the prevention of medication errors. It has been suggested that as health care takes on a more regional focus, providers are expected to reduce the rates of variance both in practice patterns and patient outcomes. To do this providers must look beyond their own institution for standards for quality comparison and measurement. Providers must also establish effective collection tools and processes that will provide complete, consistent and accurate information. This information should be standardized at a national level to ensure like data is being collected and analyzed correctly and appropriately. Overall, medication error rates are not a very useful or meaningful comparison, as they do not account for differences among hospitals. Should medication error rates be used at all, given that medication errors are defined differently in institutions or the culture may not be conducive to openly sharing medication error information? Best practices, or better practices, is more than comparing numbers. There are several approaches to develop best practices and many steps in the process. Applying best practices may lead to improved procedures, processes and even a decrease in costs. Key Research Questions What are the internal health systems medication use processes (from written or verbal order to the adverse drug event) that create an environment for error? How are the prescribers and other health care professionals educated about the process? Can these processes be mapped and models developed? What systems or processes hinder or promote quality data elements and how can the system be improved? What are the standardized data elements to be collected and what standardized definitions need to be developed? What is practical and will provide the necessary information? What are the appropriate data elements to compare and what will the data collected tell you? What processes lead to problem-prone medications? What are the quality indicators and performance measures for the medication use process? Top of PageCurrent as of September 2000 Internet Citation: U.S. Pharmacopeia. Additional Statement by Diane Cousins. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/ausp.htm Return to Additional Statement Directory |