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Council Defines Terms and Sets Goals for Medication Error Reporting and Prevention October 16, 1995 — The National Coordinating Council for Medication Error Reporting and Prevention held its second meeting on September 21, 1995, and approved the following as its working working definition of medication error: "... 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." [Click here for more information on medication errors.] Medication errors have been defined in myriad ways depending on research methodologies, incident reporting, risk management, or total quality improvement systems. The Council urges researchers to utilize this definition to provide a consistent framework, as a first step toward standardizing medication error classification and analysis. A subcommittee has been established to develop a glossary of terms expressed in the definition. Application of this definition will provide the basis for Council activities that will encourage reporting, increase understanding, and work toward prevention of medication errors. The Council's goals are: To stimulate the development and use of medication error reporting and evaluation systems in individual health care organizations. To stimulate reporting to a national system for review, analysis, and development of recommendations to reduce and prevent medication errors. To examine and evaluate the causes of medication errors. To increase awareness of medication errors and methods of prevention throughout the health care system, which includes health care organizations/facilities, delivery systems, practitioners, manufacturers, regulators, and consumers. To recommend strategies relative to system modifications, practice standards and guidelines, and changes in packaging, labeling, and product identity. To encourage reporting of medication errors, the Council will heighten awareness of reporting systems available to or within health care organizations both nationally and locally. As a first step, the Council will survey member organizations to determine the nature of systems in existence for medication error identification, tracking, and reporting. Standardized classification criteria and severity grading systems were identified as essential for the work of the Council. The Council recognized the importance of reporting systems that have feedback mechanisms established to enable appropriate parties to develop prevention strategies. Health care professionals are urged to voluntarily report medication errors to the USP Medication Errors Reporting Program (1-800-233-7767). In addition, serious adverse events (including those resulting from medication errors) may be reported to the FDA MedWatch Program (1-800-FDA-1088). The USP Medication Errors Reporting Program is a partner in the FDA MedWatch Program and is presented in cooperation with the Institute for Safe Medication Practices. To foster understanding of errors, the Council expects to conduct an ongoing literature assessment of reported medication errors by monitoring the scope, types, and causes of problems. It will then identify gaps in research that must be bridged in order to expand the medication error knowledge base. Future Council actions to prevent medication errors will address: standardization of error-prone aspects of drug prescribing, delivery, and administration; encouraging systems-based solutions to assure the safety of medication use and to minimize the potential for human error; exploring potential computer-based information systems that will aid in medication error prevention; identifying specific needs for distinctive packaging, labeling, and nomenclature for products associated with actual or potential medication errors; and educating health care professionals, consumers, and patients about strategies to prevent medication errors for prescription and over-the-counter medications. The Council also welcomed the American Society of Health-System Pharmacists (ASHP) and the American Health Care Association (AHCA) as full-voting members of the Council. The National Coordinating Council for Medication Error Reporting and Prevention was established in July 1995 with a mission to promote the reporting, understanding and prevention of medication errors. © 1998–2008 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved. *Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied.