the voluntary reporting of serious adverse events and requires the performance of root-cause analyses for such events. Beginning in 1998, JCAHO disseminated patient safety solutions via Sentinel Event Alerts, based on analyses of reported sentinel events. Since 2003, JCAHO has set annual National Patient Safety Goals (JCAHO, 2006). Many of these goals relate to medications; an example is goal 13: Encourage the active involvement of patients and their families in the patients’ care as a patient safety strategy.

In parallel with the development of guidance on the delivery of safe care, emerging technologies have been developed to improve safety. These include electronic prescribing that automates the medication ordering process; clinical decision-support systems (usually combined with electronic prescribing systems), which may include suggestions or default values for drug doses and checks for drug allergies, drug laboratory values, and drug– drug interactions; automated dispensing systems that dispense medications electronically in a controlled fashion and track medication use; bar coding for positive identification of patients, prescriptions, and medications; and computerized adverse drug event monitors that search patient databases for data that may indicate the occurrence of such an event.

Creating Health Care Organizations That Foster Safe Care

The full benefits of technologies for preventing medication errors will not be achieved unless a culture of safety is created within health care organizations that are adequately staffed with professionals whose knowledge, skills, and ethics make them capable of overseeing the medication management of patients who are vulnerable and unable to manage their medications knowledgeably themselves (IOM, 2004). Indeed, the first safe practice in the NQF report Safe Practices for Better Healthcare is the creation of a culture of safety (NQF, 2003). The IOM’s (2004) Patient Safety report outlined the elements of a culture of safety: a shared understanding that health care is a high-risk undertaking, recruitment and training with patient safety in mind, an organizational commitment to detecting and analyzing patient injuries and near misses, open communication regarding patient injury results, and the establishment of a just culture seeking to balance the need to learn from mistakes and the need to take disciplinary action (IOM, 2004).

Two of NQF’s safe practices relate to the need for adequate resources. Safe practice 3 calls for use of an explicit protocol to ensure an adequate level of nursing based on the institution’s usual patient mix and the experience and training of its nursing staff. Safe practice 5 calls for pharmacists to participate actively in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medica-

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