The National Coordinating Council for Medication Error Reporting and Prevention: The First Ten Years Executive Summary Read the full NCC MERP 10 Year Anniversary Report here. Through its work as a drug standards-setting organization and its experience with the nationwide USP-ISMP Medication Errors Reporting (MER) Program, the United States Pharmacopeia (USP) recognized that there were medication errors caused by many different factors and that no one organization was equipped to effectively address all these issues. Therefore, the USP convened several national organizations that had the authority, mechanisms, and resources to confront the complexities of medication errors and seek solutions for those issues that adversely affected patient safety. The Council was formed to actively promote the reporting, understanding, and prevention of medication errors through the efforts of its members, and to focus on ways to enhance patient safety through a coordinated approach and a systems-based perspective. Fifteen interdisciplinary organizations and agencies met on July 19, 1995, for the first meeting of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Over the past decade, the Council has grown to encompass 22 patient safety member organizations and two individual members. NCC-MERP Members AARP American Health Care Association American Hospital Association American Medical Association American Nurses Association American Pharmacists Association (previously known as The American Pharmaceutical Association) American Society for Healthcare Risk Management American Society of Consultant Pharmacists American Society of Health-System Pharmacists Department of Defense Department of Veterans Affairs Food and Drug Administration Generic Pharmaceutical Association (formerly known as The Generic Pharmaceutical Industry Association) Healthcare Distribution Management Association Institute for Safe Medication Practices Joint Commission on the Accreditation of Health Care Organizations National Association of Boards of Pharmacy National Council of State Boards of Nursing National Council on Patient Information and Education National Patient Safety Foundation Pharmaceutical Research and Manufacturers of America The United States Pharmacopeia, Inc. Deborah M. Nadzam, Ph.D., FAAN - Individual Member David Kotzin, R.Ph., BS, MS - Individual Member Major Accomplishments NCC MERP has evolved to become a well respected partner in the patient safety arena. The Council's major accomplishments over the last ten years include: Development of a standardized definition of "medication error" that has been widely adopted by CMS, FDA, USP and others Development of a taxonomy of medication errors that is widely requested by hospitals and other health care establishments Development of a severity category index of medication errors Issuance of 11 sets of recommendations directed to health professionals in an effort to prevent medication errors and focus on safe prescribing, labeling and packaging, dispensing, administering and reporting of errors Planning and convening two invitational conferences that focused on controversial, important public health issues (standardization of barcodes on medication packages and containers, and standardization of suffix use with drug nomenclature) In concert with 93 state and national associations, the Council signed on to a set of general principles supporting legislation to uphold as privileged that information submitted to error reporting programs. These principles were incorporated into the Patient Safety and Quality Improvement Act of 2005 which was passed by Congress and signed into law in July. The impact of NCC-MERP activities is evidenced by the broad use and adoption of the Council's many work products including the Taxonomy, the Index for Categorizing Medication Errors, etc. A recent Internet search revealed more than 200 hundred national and international references to NCC MERP products and their new and ongoing use. To date, many organizations have formally requested and been granted permission to use the Taxonomy. In addition, the Council's work has been quickly embraced by the international community. Many countries including Canada, the United Kingdom, Australia, and others have embedded the Taxonomy, the definition for medication error, or other components of the Council's work products into national reporting systems, patient safety best practices guidelines, and error reporting/analysis systems. In 2005, the Council submitted the Taxonomy to the World Health Organization for their unencumbered use in the World Alliance for Patient Safety project which focuses on building international consensus on a high level taxonomy that will support analysis, aggregation, and learning from patient safety data within and across countries. The Council is currently engaged in several activities that will come to fruition over the next 6-12 months including: updating previously developed recommendations and other work products to assure currency and ongoing relevance; defining the scope of the medication errors associated with tubing interchangeability; articulating and disseminating the most common risk behaviors as determined through structured evaluation of more than 600 medication error cases; developing and disseminating principles to guide the approved partial use of the taxonomy; developing a database of taxonomy users and establishing a process to routinely obtain input/feedback on the practical issues associated with the use of the taxonomy; developing and disseminating recommendations focused on the safe use of sample medications within various health care settings; and implementing follow up activities to the invitational roundtable meeting on the non-standardized use of drug suffixes in drug names NCC MERP Plan for the Future NCC MERP's strategic plan focuses on continuing to evolve its presence and role in the current patient safety environment, both nationally and internationally. As such, emphasis will be placed on continued generation of relevant and timely work products designed to help reduce/prevent medication errors and increase/improve error reporting, greater presence and participation in various national patient safety activities, and increased communications. The strategic plan also will identify and articulate potential Council projects and associated goals/objectives, potential areas that need to be monitored so that current and planned activities can be continuously informed and modified as needed, and potential project collaborators and funding sources to support planned activities. Current Council discussions indicate that future directions may include more focused attention on error-related issues in non-hospital settings such as long term care, home care and behavioral health care; predictive risk modeling; comprehensive analysis of the medication error literature over the past 10 years; initiation of a "campaign" for increased error reporting; development of a Research Agenda that targets critical error-reduction opportunities; and enhanced error reporting incentives for further investigation, reliability and validity studies respecting the Index for Categorizing Medication Errors, expansion of Council membership, and the identification of collaborative opportunities with member organizations and others. Read the full NCC MERP 10 Year Anniversary Report here. © 1998–2008 National Coordinating Council for Medication Error Reporting and Prevention. 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