Medication Safety in Oncology Practice by sammyc2007

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									Medication Safety in
 Oncology Practice


   Lita Chew
   BSc (Pharm), M.Med.Sc(Oncology), BCOP
   PHARMACY MANAGER
   NATIONAL CANCER CENTRE
 The Straits Times Weekly Edition,
        September 10, 1994
• 27 year-old patient with leukemia died after
  erroneous intrathecal administration of
  vincristine
• Drug should have been given intravenously
• Error was made by a junior house-officer only
  recently graduated from medical school
• Coroner found doctor criminally negligent in
  causing death of patient
• Physician had to endure adverse publicity and
  faced possible criminal prosecution
   Selected report from MER and
     MEDMARX, 1998 to 2003

• A physician ordered Taxotere 120mg to be
  given via IV bag over 1 hour.
• The pharmacy mistakenly prepared Taxol
  120mg.
• Nursing staff administered the dose and at the
  conclusion of the infusion questioned why the
  bag label listed “paclitaxel” despite the order
  for “Taxotere”.
• At that moment staff realised the wrong drug has
  been prepared and adminstered despite being
  checked by at least three professionals before
  administration.
   Selected report from MER and
     MEDMARX, 1998 to 2003

• An order for cytarabine was written as
  “100mg/m2 x 1.92m2=1920mg/day”.
• Patient received 11 bags of cytarabine 960mg
  infused every 12 hours as a CI before error was
  detected.
• The patient should only received 1344mg over 7
  days. This patient received 10560mg over a 5-
  day period!
   Selected report from MER and
     MEDMARX, 1998 to 2003

• Leucovorin rescue after high-dose MTX was
  ordered for a patient with osteosarcoma, but the
  order was not transcribed onto the MAR.
• The error went undetected by both pharmacy
  and nursing.
• The omission was finally detected by a nurse
  arriving for the subsequent night shift.
• However, the nurse was not aware when the
  leucovorin dose arrived in patient care area, and
  the administration was further delayed.
   Selected report from MER and
     MEDMARX, 1998 to 2003

• An order of 5-FU 1950mg in 100ml to be
  administered over 24 hours was administered to
  patient in just over three hours.
• Upon investigation, it was discovered that the
  patient‟s nurse temporarily took the 5-FU
  infusion off the infusion pump in order to run a
  flush and administer morphine.
• When the nurse reconnect the 5-FU IV, she
  failed to reset the flow rate on the pump.
          Errors in Oncology

• Chemotherapeutic agents are highly
  toxic with a narrow therapeutic index
  and safety margin

• Medication errors involving chemotherapy
  will nearly always result in adverse
  effects on clinical outcome
            Errors in Oncology
• An overdose will usually result in serious toxic
  effects and potential mortality
• Underdosing will result in undertreatemnt of
  the tumour and possible tumour progression or
  lack of response
• Inappropriate use or omission of supportive
  therapy, essential for the treatment, will have
  an impact on patients morbidity and mortality
           Errors in Oncology

• Very hard to quantify actual effects
  of errors relating to the prescribing,
  supply and administration of
  chemotherapy on outcomes due to
  the nature of both the disease and
  the drugs
          Learning Objectives
At the end of session, the participants will be able to
1.   Identify common sources of errors associated with
     the medication-use process in Oncology
2.   Identify common causes of errors associated with
     the medication-use process in Oncology
3.   List a number of practices that have been shown to
     reduce errors in the medication use process.
4.   Identify relevant references and tools for
     incorporating safety into work processes
              SCOPE
• Common sources of errors in oncology
  settings
• Common causes of error in oncology
  settings
• Lessons from an Oncology Medical
  Error Analysis
• Recommendations
• Pharmacists roles
What is a Medication Error?
"A medication error is any preventable event
that may cause or lead to inappropriate
medication use or patient harm while the
medication is in the control of the health care
professional, patient, or consumer.
Such events may be related to professional
practice, health care products, procedures,
and systems, including prescribing; order
communication; product labeling, packaging,
and nomenclature; compounding;
dispensing; distribution; administration;
education; monitoring; and use."
          The National Coordinating Council for Medication Error Reporting and Prevention
          (NCC MERP)
  Where can the doctor go wrong?

• Incorrectly interpret of patient results,
  patients records, dr‟s instructions
• Incorrectly interpret or incorrectly apply a
  published paper or written drug protocol
• Incorrectly use, apply or calculate patient
  data (BSA, GFR)
• Make an actual error transcribing the
  prescription of the medication(s)
• Write an order that is correct BUT unclear
  or illegible and open to misinterpretation
  by other health care professions
  Where can pharmacist go wrong?

• Fail to pick up on an error made by the
  prescriber and proceed to a supply error
• Misinterpret a correct order and
  proceed to make a supply error
• Make a supply error on a correct order
   – wrong drug, dose, wrong route,
     wrong day, wrong time , wrong label,
     wrong place
Where can the nurse go wrong?
• Fail to pick up on an error made by the
  prescriber &/or pharmacy & proceed to
  an administration error
• Misinterpret an order & proceed to an
  administration error
• Make an administration error
   – wrong drug, wrong dose, wrong time,
     wrong duration, wrong route, wrong
     patient
 Where can the patient go wrong?

• Misinterpret medication directions
  and proceed to a medication
  administration error
• Fail to pick up on an error made by
  the prescriber &/or pharmacy and
  proceed to a medication
  administration error
     Doctor                Pharmacist                  Nurse                       Patient

                      Pharmacist intercept     Nurse intercept dr’s             Patient
                      dr’s error and           error (that pharmacy            receives
                                                                                correct
Dr can make an        corrects                 missed)
                                                                                medication etc
error in diagnosis,
                      Pharmacist does not      Nurse does not pick up
treatment decisions
                      pick up error &          error & proceeds to
                                                                            
or prescribing
                      proceeds to              dispense/supply                  Patient
                      dispense/supply                                           receives
                                                                                incorrect
                                               Nurse intercept dr’s
                      Drs orders are           misinterpreted error            medication

Dr writes a order     misinterpreted &
                      incorrect drug/dose      Nurse also misinterprets a
that is correct but
                      supplied to              dr order & makes an
                                                                            
is open to
misinterpretation     nurse/patient            error in administration

                                               Nurse makes an error in      
                      Pharmacy provide         administration                    Patient mis-
                      correct interpretation                                     administers
                                                                                 dose
                      & supply correct         Nurse gives correct med      
                      drug/dose
                                                                                 Patient
Dr writes a correct                            Nurse does not pick up            intercepts
order                                          error- proceeds to               error in
                      Pharmacy makes a         administer                        prescribing,
                                                                                 supply or
                      dispensing or supply
                                                                                 administration
                      error                    Nurse intercepts
                                               pharmacy error &
                                               corrects
                                                                            
     Doctor                Pharmacist                  Nurse                       Patient

                      Pharmacist intercept     Nurse intercept dr’s             Patient
                      dr’s error and           error (that pharmacy            receives
                                                                                correct
Dr can make an        corrects                 missed)
                                                                                medication etc
error in diagnosis,
                      Pharmacist does not      Nurse does not pick up
treatment decisions
                      pick up error &          error & proceeds to
                                                                            
or prescribing
                      proceeds to              dispense/supply                  Patient
                      dispense/supply                                           receives
                                                                                incorrect
                                               Nurse intercept dr’s
                      Drs orders are           misinterpreted error            medication

Dr writes a order     misinterpreted &
                      incorrect drug/dose      Nurse also misinterprets a
that is correct but
                      supplied to              dr order & makes an
                                                                            
is open to
misinterpretation     nurse/patient            error in administration

                                               Nurse makes an error in      
                      Pharmacy provide         administration                    Patient mis-
                      correct interpretation                                     administers
                                                                                 dose
                      & supply correct         Nurse gives correct med      
                      drug/dose
                                                                                 Patient
Dr writes a correct                            Nurse does not pick up            intercepts
order                                          error- proceeds to               error in
                      Pharmacy makes a         administer                        prescribing,
                                                                                 supply or
                      dispensing or supply
                                                                                 administration
                      error                    Nurse intercepts
                                               pharmacy error &
                                               corrects
                                                                            
    Why Do Errors Occur?
   (From: To Err is Human (IOM) Pg 65)

• Some systems are more prone to
  accidents than others because of
  the way the components are tied
  together.
• Health care services is a complex
  and technological industry prone to
  accidents
   Why is chemotherapy a high                 risk drug?
  Medications may be classified as high risk drugs where they
   are more susceptible to error & where an error has a high
 probability of resulting in serious harm or death to the patient

• Chemotherapy/cytotoxic agents are
  classified as high risk drugs with a high
  potential to cause harm due
  – to the pharmacology of the agents &
    associated toxic side effects
  – the actual context in which they are
    used
  Why is chemotherapy a high   risk drug?

• Treatment with chemotherapy involves
  complex protocols involving a number of
  highly toxic drugs
• Doses are calculated on an individual basis
  based on patients parameters i.e. height,
  weight, GFR
• Doses and schedules frequently need to be
  altered according to laboratory results &
  patient parameters
    Why is chemotherapy a high         risk drug?
•   Drugs are used at a wide range of doses &
    scheduling according to the tumour group
•   Many agents are used outside product
    information indications minimising the availability
    of prescribing information found in „usual‟
    sources
•   The complex and life threatening side effects of
    chemotherapy mean that additional supportive
    therapy forms an essential part of the treatment
     – Appropriate supportive therapy is critical to
       the success or failure of the treatment and the
       patients well being
               Same drug, different dose
Methotrexate   RA/ALL            Breast            ALL                  Sarcoma,
                                 CMF                                    lymphoma
               5mg-20mg weekly                     HYPERCVAD-
               IM or orally      40mg/m2 IV        HIDACMTX             8 grams/m2
                                 every 21 days     1gram/m2        IV   IV over 24 hours
                                                   over 24 hours

Cyclophos-     CLL               Breast            Lymphoma             Stem cell
               200mg/m2          600mg/m2          CHOP                 mobilisation
phamide
               oral              IV                750mg/m2 IV          4grams/m2 IV


Busulphan      CML               Stem cell transplants
               0.1/mg/kg/day     4mg/kg/day
               Approx 6 mg       Approx 240mg

Fluorouracil   Colorectal        Head & Neck 1000mg/m2/day
               225mg/m2/day      for 4 days out of 21 only
               CONTINUOUS
               For 12 weeks
    Why is chemotherapy a high        risk drug?
•   No defined way of expressing chemotherapy
    regimens and scheduling and the use of acronyms
    for naming protocols can add to the potential for
    confusion
     – e.g. CHOP, Hyper CVAD/HiDAC MTX, R-ICE,
       ICE
•   Dosing scheduling & cycling can be complex and
    confusing
     – Use of day 1, 4 etc to nominate the schedule
     – Giving drugs every 14, 21 or 28 days
        Where do we start ?!
• Look at WHY the errors happen

   – Retrospective - after the event of an error
      • Uses your own experience
   – Prospective - before the event of an error
      • Uses someone else's experience
              Why can the doctor make an error?
            Error                                                      Why?

Incorrect or misinterpretation   Notes unclear, disorganised not available
of patient results/medical       Does not have the knowledge/competency to make an informed decision
records/ another doctors         Verbal instructions given no written clarification
instructions

Incorrect interpretation or      Does not have the knowledge/competency
application of drug protocol     Error in published paper
                                 Protocol is unclear, ambiguous
                                 Human error in prescribing

Incorrect use/application or     Does not have the knowledge/competency
calculation of patient data      Human error in calculation
(BSA, GFR                        Lack of supporting information/resources

Write an order that is correct   Illegible writing, order unreadable due to faxing, carbon copy, photocopy
BUT unclear or illegible and     Use of trade names, abbreviations, non standard drug names or units
open to misinterpretation by
other health care                Use abbreviations of routes of administration (SC-SL)
professions                      Abbreviation of timings, frequencies, instructions
                                 Inappropriate use of the decimal point
                                 Prescription form is not „user friendly‟
         Why can the pharmacist make an error?
            Error                                                   Why?

Fail to pick up on an error    Does not have the knowledge/competency
made by the prescriber and     Does not follow clear prescription validation procedure
proceed to a supply error
                               Does not have access to appropriate data and/or information
                               Protocol/prescription is unclear, ambiguous


Misinterpret a correct order   Does not have the knowledge/competency
and proceed to make a          Does not follow clear prescription validation procedure
supply error
                               Does not have access to appropriate data an/or information
                               Protocol/prescription is unclear, ambiguous
                               Unaware of vulnerable area of errors


Make a dispensing/supply       Does not have the knowledge/competency
error                          Does not follow clear prescription validation procedure
                               Does not have access to appropriate data an/or information
                               Prescription is unclear, ambiguous
                               Procedures unclear/unavailable
                               Human error in calculation/dispensing/supply
         Why can the nurse make an error?
              Error                                                     Why?
Fail to pick up on an error made   Does not have the knowledge/competency
by the prescriber/pharmacist and
proceed to a supply error          Does not follow clear medication validation procedure
                                   Does not have access to appropriate data and/or information
                                   Protocol is unclear, ambiguous

Misinterpret a correct order and   Does not have the knowledge/competency
proceed to make an
administration error               Does not follow clear medication validation/administration procedure
                                   Does not have access to appropriate data an/or information
                                   Prescription is unclear, ambiguous
                                   Unaware of vulnerable area of errors

Make an administration error       Does not have the knowledge/competency
                                   Does not follow clear administration procedure
                                   Does not have access to appropriate data and/or information
                                   Prescription is unclear, ambiguous
                                   Labelling of product is unclear/ambiguous
                                   Procedures unclear/unavailable
                                   Human error in administration
    USP Medical Error Analysis
 • An analysis conducted on reports submitted to
   USP's MEDMARX error reporting program
   revealed 3,871 errors involving oncology drug
   products reported during the 5-year period from
   September 1, 1998 to August 31, 2003.
 • majority (88%) of the actual errors (Categories B-
   D) did not cause harm, while nearly 3% did result
   in some level of patient harm ranging from
   temporary harm to death.

“Errors involving oncology drug products are a concern because most oncolytic agents
    have a narrow therapeutic index and are toxic even at therapeutic dosages”
     NCC MERP Taxonomy of
       Medication Errors
•   A:   No error, but potential for error
•   B:   Error caught before med reached patient
•   C:   Med reached patient; no harm
•   D:   Increased monitoring; no harm
•   E:   Temporary harm requiring intervention
•   F:   Temporary harm requiring hospitalization
•   G:   Permanent harm
•   H:   Near death
•   I:   Death
         National Coordinating Council for Medication Error Reporting and
                        Prevention (NCC MERP) http://www.nccmerp.org
MEDMARX Error Analysis –
    Types of Error
MEDMARX Error Analysis –
    Causes of Error
MEDMARX Error Analysis –
Oncology Products Involved
  MER Error Analysis –
Oncology Products Involved
    To Guard Against Error…
• Physician /Nursing/ Pharmacy Champions
    • Decreased perception that any dept is
      a barrier to patient care
• System
    • Policy and Procedure
       – Standards and Practices
    • People
• Environment
    • Supportive of system and champions
    • Non-punitive
      Policy and Procedures
• Need appropriate procedures &
  polices in place to provide direction
  and clear instruction on working
  practices which minimise the
  possibility of errors
• All staff must be familiar with the
  content
• Must be approved, available and up
  to date
    To Guard Against Error…
• Physician /Nursing/ Pharmacy Champions
    • Decreased perception that any dept is
      a barrier to patient care
• System
    • Policy and Procedure
       – Standards and Practices
    • People
• Environment
    • Supportive of system and champions
    • Non-punitive
              People (Staff)
• Ensure that all staff who are involved in the
  management of cancer and chemotherapy
  are competent to perform the functions

   – Education & knowledge base
   – Experience & skills
   – Competency
      • should be measurable as an indictor
        of actual ability to perform duties
    To Guard Against Error…
• Physician /Nursing/ Pharmacy Champions
    • Decreased perception that any dept is
      a barrier to patient care
• System
    • Policy and Procedure
       – Standards and Practices
    • People
• Environment
    • Supportive of system and champions
    • Non-punitive
    Safe Medication Practices
• A number of practices have been shown to reduce
  errors in medication process. These include:


(1) Reduce Reliance on Memory
   – Use drug-drug interaction checking systems
   – Use computerised order entry
   – Use bar-coding on drugs, containers,
     medication records, patient wristbands
   – Use computerised patient information
   – Use guided dose algorithms
    Safe Medication Practices
(2) Simplify
  – The antidote for complexity is simplification.
    Fewer steps lead to fewer errors
  – Eliminate transcription of orders
  – Limit choices of available drugs in pharmacy
  – Limit dosage strengths and concentration for
    each drug
  – Mix IVs in the pharmacy
  – Automate dispensing on the unit
   Safe Medication Practices
(3) Standardise
  – Standardisation reduces the opportunities for
    error
  – Standardise prescribing conventions:
     • no abbreviations
     • use generic names
     • use “units” not “u”, etc
     • Use protocols for complex medication
       administration (heparin, insulin,
       chemotherapy)
  – Standardise times of drug administration
  – Store medications in the same place in every
    medication room
  – Use standard equipment, e.g. one kind of
       Safe Medication Practices
(4)   Use Constraints and Forcing Functions
      – A forcing function is an effective error-proofing
        method that eliminates relying on memory,
        checklists, and double check systems.
      – A constraint prevents further action until some
        condition is met.
         • Use pharmacy computers that will not fill any
           orders unless allergy info, patient weight and
           height are entered
         • Use special luer-locks to syringes and indwelling
           lines that have to match before fluid can be
           infused
         • Use computerised order entry with dosage
           range checks
   Safe Medication Practices
(5) Use Protocols and Checklists Wisely
  – Protocols support standardisation.
  – Checklists serve as reminders of critical tasks,
    especially when an omission can have serious
    consequences. They reduce individual
    variation in practice, but can be a source of
    error with indiscriminate adherence.
  – Make sure that everyone has agreed on
    protocol or checklist, and is aware that it is in
    use
  – Revisit the protocol or checklist regularly to
    evaluate and update
        Safe Medication Practices
(6)    Improve Access to Information
      Lack of information is a common cause of errors.
      – Have a pharmacist available on nursing units and
         at rounds
      – Use computerised order entry systems
      – Use computerised laboratory data
      – Colour-code wristbands for patients with allergies
      – Provide patient with list of his/her medications,
         doses, and frequency
      – Track errors or near misses and report to staff
         regularly
       Safe Medication Practices
(7)      Decrease Reliance on Vigilance
        There are limits to the human attention span. It is
        difficult to maintain vigilance in situations of
        fatigue, repetitive tasks, and infrequently occurring
        events.
      – Use double check system
      – Use automatic drug dose checking in high-risk
        situations
      – Use electronic monitors that signal alarm when
        parameters are exceeded
      – Rotate staff when performing repetitive functions
      – Limit long shifts
      Safe Medication Practices
(8)    Reduce Handoffs
  The complexity in the medication system is a
  result of the number of people involved and
  the handoffs among them.
  Many errors occur during transfer of
  materials, information, people, instructions,
  or supplies.
      • Provide ready-to-administer products
      • Reduce transcription of medication
        orders
      • Use unit dosing systems
      • Use automated drug dispensing / filling
        systems
      Safe Medication Practices
(9) Differentiate : Eliminate Look-Alikes and
    Sound-Alikes
   Similarity in packaging/labeling can cause mix-
   ups in the supply and use of drugs.
  –     Avoid stocking look-alikes
  –     Store similar-looking medications in
        separate places
  –     Repackage or re-label look-alikes to
        differentiate them
  –     System to alert staff and post information
       • Use striking caution stickers on stock
           containers to alert staff to look-alikes
   Safe Medication Practices
(10) Automate Carefully
 Automation can reduce errors that occur in
 repetitive tasks or in tasks requiring attention to
      details. It can become hazardous, when it
 leads staff to feel less responsibility for the task.
 It can also multiply an error if the error is made in
 generating inputs to the system.

  – Use CPOE systems with range checks
  – Use robotic dispensing system in pharmacy
  – Train staff to double check the automation
    regularly
  – Use bar-code technology to identify drugs
      How do we implement safeguards?

     1. Safety is a system property
              Cooperation among practitioners
              Build transparency in system
              Information flow established within system
              Build checks within the system



Fallibility is part of the human condition.
We cannot change the human condition.
But we can change the conditions under which people work.
    Outcomes achieved thru CPOE

•   Reduce Reliance on Memory
•   Simplify
•   Standardise
•   Use Constraints and Forcing Functions
•   Improve Access to Information
•   Decrease Reliance on Vigilance
•   Reduce Handoffs
Some problems after e- Rx
•   Incorrect patient selection
•   Wrong items selected
•   Incomplete/wrong doses
•   Drug allergies, drug interactions
•   Additional handwritten
    orders/instructions
Recommendation for Safe Use of CPOE

• While there is no "cookbook" approach for
  handling the magnitude and complexity of CPOE,
  the references below may be useful …
  – Landmines and Pitfalls of Computerised
    Prescribers Order Entry. Institute for Safe
    Medication Practices.
    Accessed at http://www.ismp.org

  – Guidelines For Safe Electronic
    Communication of Medication Orders.
    Institute for Safe Medication Practices.
    Accessed at http://www.ismp.org
Application 2.….
  Building Checks
• Dos and Don‟ts list
• Audit checklist
      How do we implement safeguards?

     2. Identifying system weaknesses
        • Failure Mode and Effect Analysis
          (FMEA): Proactive Risk Reduction



Fallibility is part of the human condition.
We cannot change the human condition.
But we can change the conditions under which people work.
             What Is FMEA?

• It is a systematic method of identifying
  and preventing product and process
  problems before they occur.
• It is a quality improvement tool – but unlike
  many tools it does not require complicated
  statistics.
• FMEAs do take time and people resources
  because they are TEAM BASED.
    The 10 Steps of FMEA Process

1. Review the process
2. Brainstorm the potential failures
3. List potential effects of each failure
   mode
4. Assign a severity rating for each
   effect
5. Assign a frequency (occurrence)
   rating for each failure mode
     The 10 Steps of FMEA Process

6. Assign a detection rating for each failure
    mode
7. Calculate the risk priority number (RPN)
    for each effect
8. Prioritize the failure modes for each
    action
9. Take action to eliminate or reduce the
    high risk failure modes
10. Calculate the resulting RPN as the failure
    modes are reduced or eliminated.
  Evaluating the Risk of Failure
• The relative risk of a failure and its effect
  are determined by three factors:
  Severity
  Frequency
  Detection
• Assessing the risk number (severity x
  frequency x detection) = risk priority
  number (RPN)
How do we implement safeguards?

3. Build staff competency
  •   Training and Validation
      – Require all involved staff to undertake
        specific training that demonstrates their
        competence with verifying and processing
        orders
  •   Staff Audit
      – Ensure that staff are aware of existing
        policies and procedures and can
        demonstrate their familiarity
  •   Keep updated!
Build a “change of the heart’ too…

• habits, attitudes and beliefs




      • Change people – plastic surgery only change the
        external features of a person
      • Change the structure and system – this is
        „skeletal change‟
         – No soul, no spirit, no life
    How do we implement safeguards?
4. Build Quality Processes & Risk Management
‘What you don’t measure, you can’t improve’
•   Robust tracking & reporting system
      • Electronic incident reporting system
           – Rapid and prompt notification
           – Clear follow-up actions
           – Data tracking made easy
           – Reporting of near misses encouraged by anonymous
             reporting
      • National Sentinel Event Reporting System (2002)
           – Root cause analysis approach helps to focus on system
             review instead of blame on people
• Trigger tools to detect adverse drug events
• Encourage reporting!
• Continuous monitoring!
  Pharmacist’s Integral Role

• To promote a safe environment
  - to minimize opportunities for
  error
• Check / Intervene actively in
  medication use process - to
  prevent errors from happening
The following areas are recommended
for pharmacist participation:
1. Educate health care providers about medication errors,
2. Independently verify medication dosages, routes of
   administration, and schedules,
3. Participate in multidisciplinary efforts to establish
   drug-specific utilization constraints that limit maximum
   doses, administration rates, and administration
   schedules for antineoplastic medications,
4. Participate in multidisciplinary efforts to standardize
   the prescribing vocabulary,
5. Participate in multidisciplinary efforts to educate patients,
   their families, and personal caregivers,
6. Improve communication among health care providers
   and among health care providers, patients, and caregivers,
7. Work with drug manufacturers.
                                      ASHP Guidelines on Preventing Medication Errors
                                                            with Antineoplastic Agents
      SUGGESTED READINGS
• Books
1. Cohen, Michael R., Ed. Medication Errors. Washington, D.C.
   American Pharmaceutical Association. 1999. (Contains a special
   chapter on high-alert medications and dangerous abbreviations; rich
   with insight and practical advice on reducing the risk of error.)
2. Corrigan, Janet, et al. To Err is Human: Building a Safer Health
   System. Washington, D.C. National Academies Press. 1999.
   (Comprehensive overview of medical error, containing many
   practical suggestions and recommendations from several trusted
   sources.)
3. Leape, Lucian, et al. Reducing Adverse Drug Events. Boston, MA:
   Institute for Healthcare Improvement. 1998. (Concepts to reduce
   adverse events and a model for improvement.)
      Organisations offering Safe
         Medication Practices
• Institute for Safe Medication Practices (ISMP) www.ismp.org
• Joint Commission on Accreditation of Healthcare Organizations
  (JCAHO) www.jcaho.org
• California Institute for Health Systems Performance (CIHSP)
  www.cihsp.org
• National Coordinating Council for Medication Error Reporting
  and Prevention (NCCMERP) www.nccmerp.org
• VA National Center for Patient Safety www.patientsafety.gov
• American Hospital Association www.aha.org
• US Pharmacopeia (USP) www.usp.org
• Med-E.R.R.S. www.med-errs.com
• American Society of Health-system Pharmacists (ASHP)
  www.ashp.org

								
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