Preventing Medication-Related Patient Harm | Quality Matters | U.S. Pharmacopeia Blog
 // June 09, 2015

Preventing Medication-Related Patient Harm

Preventing medicine-related patient harm
Contributors:

The National Coordinating Council for Medication Error Reporting and Prevention’s (NCC MERP) expansive name belies the aspirational simplicity of its vision: no patient will be harmed by a medication error. To arrive at this goal, NCC MERP’s member organizations—some of the most important voices in healthcare from the public and private sectors—had to confront the peculiar relationship between the healthcare industry and that most human of actions: making a mistake.

While many individuals dismiss mistakes as ubiquitous and expected, healthcare professionals do not possess this same casual luxury.  A mistake in healthcare may cost a life, and this makes medication error ownership a professional and moral challenge.  

Advancements in medicine are the boon and burden of healthcare professionals: they transform the impossible into the probable, but they also conceal the universal certainty of preventable errors. NCC MERP posits that mistakes present impactful learning opportunities, inspire meaningful collaborations, and create positive changes.

Founded in 1995, NCC MERP advocates for medication error reporting by individual health care organizations to the Institute for Safe Medication Practices (ISMP) or the United States Food and Drug Administration’s MedWatch.  NCC MERP also provides a full suite of resources for healthcare professionals and consumers—all of which would not be possible without healthcare organizations acknowledging errors, sharing them with others in the healthcare space, and transforming a negative experience into a learning opportunity that ultimately benefits the patient.

A Common Language for Medication Errors

Standardization is one of the keys to improved understanding and prevention. To this end, NCC MERP urges healthcare professionals, researchers, and health-related software developers to use its definition of a medication error. The organization further provides medication error indices that allow for consistent error tracking.

NCC MERP’s Taxonomy of Medication Errors creates a standardized medication error language for recording and tracking medication errors in a database. This standardized way of describing errors can be used to analyze trends and determine error severity—with an eye toward preventing an error from recurring.

Eliminating Errors at the Source – the Adverse Drug Event Algorithm

The Adverse Drug Event Algorithm looks specifically at medication error harm by examining every aspect of the medication use cycle, and makes distinctions between preventable and non-preventable patient harm. If an error that harms a patient is determined to be preventable, the algorithm enables the user to identify where in the medication use cycle the harm occurred so that protections may be put in place to prevent another patient from incurring the same harm.

Support for Healthcare Professionals

NCC MERP offers support to healthcare professionals in a variety of ways. Notable current contributions include statements on eliminating time guarantees in community pharmacies and opposing criminalization of errors in healthcare.

Consumer Resources

For consumers, NCC MERP provides a wealth of resources for safe medication use and information gathering.

Learn more about NCC MERP by visiting their Web site. USP is a founding member and current secretariat of NCC MERP. Learn more about USP’s work with healthcare professionals.