the Patient Safety and Quality Improvement Act of 2005 (P.L. 109-41), protecting such data reported to patient safety organizations, community pharmacies should start sharing this information.

Audits in community pharmacies involve random inspections of prescriptions waiting to be picked up. A double-check of the contents of the prescription vial compared with the drug and strength listed on the label can help detect wrong-drug and wrong-strength errors that may have avoided detection during the normal processes. The patient name on the vial can be compared with the identifying information on the bag to help detect wrong-patient errors. An additional audit technique is to review information entered into the computer for new prescriptions for accuracy. Use of such a quality improvement process at a VA outpatient pharmacy resulted in a decrease in serious errors (ones that could have led to patient harm) from 0.6 percent to 0.1 percent of prescriptions over a 1-year period (Boneberg et al., 1991).

Analysis of Safety Data

Time spent detecting, reporting, and analyzing medication errors and ADEs is wasted if the resulting information is not used to prevent future errors and injuries. USP publishes focused analyses based on voluntary reports made to the MedMARx database, which are helpful in identifying problem areas and can serve as one model for how to use this type of data (Young, 2002; Hicks et al., 2004; Santell et al., 2004). As noted earlier, the ISMP newsletter contains not only descriptions of problems reported, but also suggestions for preventing future errors (ISMP, 2005a). And AHRQ’s Web M&M site also provides clinically useful analyses of medication errors. Medication error databases at all levels should have a greater ability to track effective methods for preventing the errors described, with a requirement to report on follow-up actions taken and their effectiveness.

An important benefit of using the techniques of computerized detection and observation described above is that they can be used to evaluate interventions (Evans et al., 1994a, 1998). Observation, for example, enables valid measurement of the effects of error prevention efforts on medication administration errors. Studies that use voluntary reports to assess interventions cannot determine whether an intervention led to a decrease in errors or whether staff were unaware of errors that occurred.

The knowledge base on effective error prevention techniques should be advanced at all levels (local, state, and national). The ultimate goal is to have in place a system that facilitates the identification of best practices for preventing errors and dissemination of this information to providers across settings of care.



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