Print

Council States Comparing Medication Error Rates Is of No Value July 10, 2002 Rockville, Maryland—The National Coordinating Council for Medication Error Reporting and Prevention (Council), at its June 11–12, 2002, meeting approved a statement refuting the use of medication error rates. The statement, which is posted on the Council's Web site (www.nccmerp.org), states the "Use of medication error rates to compare health care organizations is of no value." The Council has taken this position for the following reasons: Differences in culture among health care organizations can lead to significant differences in the level of reporting of medication errors. Differences in the definition of a medication error among health care organizations can lead to significant differences in the reporting and classification of medication errors. Differences in the patient populations served by various health care organizations can lead to significant differences in the number and severity of medication errors occurring among organizations. Differences in the type(s) of reporting and detection systems for medication errors among health care organizations can lead to significant differences in the number of medication errors recorded. According to the statement, "The Council believes that there are no acceptable incidence rates for medication errors. The goal of every health care organization should be to continually improve systems to prevent harm to patients due to medication errors. Health care organizations should monitor actual and potential medication errors that occur within their organization, and investigate the root cause of errors with the goal of identifying ways to improve the medication use system to prevent future errors and potential patient harm. The value of medication error reporting and other data gathering strategies is to provide the information that allows an organization to identify weaknesses in its medication use system and to apply lessons learned to improve the system. The sheer number of error reports is less important than the quality of the information collected in the reports, the health care organization's analysis of the information, and its actions to improve the system to prevent harm to patients." "The Council's recommendations support the concept that, at this time in the patient safety journey," said John R. Combes, M.D., Council chairperson and senior medical advisor at The Hospital and Healthsystem Association of Pennsylvania and the American Hospital Association, "it is more important to create the open environment that encourages the reporting of errors and near errors than to develop less meaningful comparative error rates. The goal for an organization's medication safety programs," he continued, "is to learn as much as possible about active and latent error and through that understanding prevent harm to patients." # # # # 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. 2002-01 NCC MERP © 1998–2010 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.