Contact: Ellen Wilcox
ASHP PROPOSES CRITICAL STEPS IN NATIONAL SOLUTION TO MEDICAL ERROR PROBLEM
The American Society of Health-System Pharmacists (ASHP) today proposed a comprehensive, national approach to reducing medication and other medical errors. The Society, which represents 30,000 pharmacists who practice in hospitals and other components of health systems, is advocating the establishment of a national medical error reporting system and the strengthening of voluntary reporting systems.
"We need to move beyond the culture of blame that has traditionally surrounded the issue of medical error and begin to establish standardized reporting systems that take a 'lessons-learned' approach to the problem," said ASHP President Bruce E. Scott, M.S., FASHP. "The ideal system would allow sunshine into the processes that create error so that we can change those processes and protect patients."
In response to today's Senate Committee on Health, Education, Labor, and Pensions hearing, ASHP stated that a mandatory reporting system should only be applied when patients are seriously harmed or die as a result of error. "This system should focus on three primary goals: accountability, quality improvement, and enhancement of patient safety," noted Scott. The Society's recommendations are in direct response to the Institute of Medicine's recent report on medical error, "To Err is Human: Building a Safer Health System," which highlighted the important role of pharmacists in preventing medication errors, especially through their work on patient-care teams.
ASHP supports a mandatory medical error reporting system at the state level with strong federal coordination, analysis, and oversight. This system would:
-- Focus on improving health care processes,
-- Provide confidentiality to patients, health care workers, and institutions as long as the confidentiality doesn't compromise public accountability, and
-- Eliminate penalties for either the reporting of or involvement in a medical error that causes serious harm or death.
Further, the Society recommends the adoption of a definition of "serious harm" that focuses on incidents of long-term or irreversible patient harm. It also advocates that a mandatory system include national coordination and standardization of reporting methods and analysis, adequate resources for report analysis and quality improvement, and periodic assessment to ensure the system is working and not creating undesirable consequences.
ASHP also weighed in today on the importance of maintaining and improving current voluntary reporting systems. The Society noted that the current Medication Errors Reporting Program operated by the U.S. Pharmacopeia in cooperation with the FDA's MedWatch program and the Institute for Safe Medication Practices could serve as a model for voluntary reporting of other types of medical error.
"By developing a mandatory system that assesses error and by incorporating the information we learn from voluntary systems on 'near misses,' we can design a system that is truly fail-safe," said Henri R. Manasse, Jr., Ph.D., Sc.D., ASHP executive vice president and CEO. Manasse also serves as chairman of the National Patient Safety Foundation.
For a full copy of the "ASHP Statement on Reporting Medical Errors" and related resources such as the "ASHP Guidelines on Preventing Medication Errors in Hospitals," see the Society's Web site at www.ashp.org.
ASHP is the 30,000-member national professional association that represents pharmacists who practice in hospitals, health maintenance organizations, long-term care facilities, home care, and other components of health care systems. ASHP, which has a long and distinguished history of medication error prevention efforts, believes that the mission of pharmacists is to help people make the best use of medicines. Assisting pharmacists in fulfilling this mission is ASHP's primary objective. The Society has extensive publishing and educational programs designed to help members improve their delivery of pharmaceutical care, and it is the national accrediting organization for pharmacy residency and pharmacy technician training programs.
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