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Definitions of Medication Errors Broadened June 12, 2001 Rockville, MD — A revised and expanded Index for Categorizing Medication Errors has been developed by the National Coordinating Council for Medication Error Reporting and Prevention (Council) to make it easier for health care professionals to categorize and report medication errors. The Council has created a new circular configuration for its Index, which attributes an equal area to each of the nine medication error categories. "We consider all medication errors—including potential errors—to be of equal importance," said Council Chairperson Jerry Phillips, associate director for medication error prevention, Office of Post-Marketing Drug Risk Assessment, Food and Drug Administration. "By categorizing all medication errors in a circular arrangement, we are encouraging health care professionals to report and track potential errors as often as they report errors that result in harm to the patient." Previously, the Index listed the categories in descending order. Medication error definitions within each category also have been expanded. Although the nine Index categories remain the same (designated as Categories A-I), the definitions within each category have been clarified so that practitioners can more easily apply the Index to individual reports of medication errors. For example, in the previous version of the Index, to categorize an error as harmful, it was necessary to prove that the error itself harmed the patient. Because many patients have preexisting illnesses, it was often difficult to establish that the error was the only factor that caused harm. The revised index has expanded the definition so that the error "may have contributed to or resulted in" harm. Another Index refinement includes additional language for serious errors that result in an intervention necessary to sustain life. For example, a patient who suffers from an allergic reaction to a medication administered in error may require some form of intervention (such as epinephrine) to save his or her life. While the patient suffers no long-term effects, without the intervention the error may have resulted in permanent or fatal outcome. The definition of harm also has been broadened to include pain. This is consistent with a movement within health care to routinely monitor a patient’s pain as the "fifth" vital sign. The Council has created the NCC MERP Index for Categorizing Medication Errors Algorithm that incorporates a series of "yes-no" questions to guide health care professionals in their determination of the appropriate medication error category for the error they are categorizing. "We want to make it as easy as possible for health care professionals to consistently report and categorize medication errors," continued Phillips. The Council originally adopted the index in 1996 to classify an error according to the severity of the outcome. The purpose of the index is to help health care practitioners and institutions track medication errors in a consistent, systematic manner. The index considers factors such as whether the error reached the patient and, if the patient was harmed, to what degree. The Council encourages the use of the Index in all health care delivery settings and by researchers and vendors of medication error tracking software. For additional information about the Council, its activities or membership, contact Council chairperson Jerry Phillips (301/827-3246), or Council secretary Diane D. Cousins (301/816-8215). # # # #
The National Coordinating Council for Medication Error Reporting and Prevention (Council) was founded in 1995 to promote the reporting, understanding and prevention of medication errors. The Council comprises health-related organizations, societies and agencies, including medicine, pharmacy and nursing groups, consumer groups, standards-setting and federal regulatory bodies, and manufacturers. The Council’s goals are to examine and evaluate the causes of medication errors; increase awareness of medication errors and methods of prevention throughout the health care system; recommend strategies relative to system modifications, practice standards and guidelines; stimulate development and use of medication error reporting and evaluation systems; and stimulate reporting to a national system for review, analysis and development of recommendations to reduce and prevent medication errors. 2001-02 NCC MERP
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