USP Releases First-Ever Case Study Book to Advance Medication-Error Prevention


ROCKVILLE, Md. -- The United States Pharmacopeia (USP) today released Advancing Patient Safety in U.S. Hospitals: Basic Strategies for Success, a first-ever case study book featuring actual hospital medication errors and steps taken to prevent similar mistakes.

"This unique book was written to help hospitals and health care systems reduce medication errors and facilitate a culture change that embraces error reporting systems," explained Diane Cousins, RPh, vice president of the Center for the Advancement of Patient Safety (CAPS) at USP.

More than two dozen healthcare administrators and practitioners were interviewed for this book, representing large and small U.S. hospitals. Their telling accounts describe the steps they have taken to change their hospitals' cultures of blame; how they convinced staff members to report more medication errors; how error reports are analyzed to identify trends; and how their hospitals have instituted process changes to reduce medication errors.

"Without error reporting, we cannot identify and implement the system and process changes necessary to eliminate medication errors," Cousins said. "Many of the first-person accounts in this book offer situations familiar to many health care practitioners. We believe hospitals and healthcare institutions nationwide will find the book's information a valuable resource and tool for building a safer healthcare system."

In addition to first-person accounts, USP offers 10 recommendations to improve medication safety in health facilities. Among the recommendations: adopt a non-punitive policy for reporting potential and actual medication errors; create open lines of communication among departments and disciplines; and provide incentives for participating in the medication safety reporting system.

USP operates MEDMARX, the national, Internet-accessible anonymous reporting database that hospitals and healthcare systems use to track and trend medication errors. Hospitals and healthcare systems participate in MEDMARX voluntarily. USP created MEDMARX to help healthcare facilities understand the causes of medication errors and the factors that contribute to them in order to improve patient care and safety.

MEDMARX helps hospitals report, understand and ultimately prevent medication errors in hospitals. The MEDMARX data report, "Summary of Information Submitted to MEDMARX in the Year 2002: The Quest for Quality," provides a comprehensive analysis of 192,477 medication errors as voluntarily reported by 482 hospitals and healthcare facilities nationwide, including community, government and teaching institutions. MEDMARX is the nation's largest database of medication errors, containing more than 580,000 released records.

To order a copy of the book, go to:

Source: USP

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