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Medication Error Reporting (Resolution No. 103-5-07)
Resolution Number: 103-5-07
Title: Medication Error Reporting
Action: Passed
Whereas, the 2006 Institute of Medicine (IOM) Preventing Medication Errors: Quality Chasm Series, formally recommends boards of pharmacy implement quality improvement initiatives related to community pharmacy practice; and
Whereas, the aforementioned IOM Report suggests that medication error reporting be promoted more aggressively by all stakeholders; and
Whereas, NABP and boards of pharmacy have endorsed the reporting of medication errors most recently by formal recommendation of the 2004-2005 NABP Task Force to Develop Recommendations to Best Reduce Medication Errors in Community Pharmacy Practice and also by guidance as included in the Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy (Model Act);
THEREFORE BE IT RESOLVED that NABP continue to actively support boards of pharmacy by encouraging and promoting the reporting of medication errors occurring in all pharmacy practice settings to reporting programs such as the United States Pharmacopeia-Institute for Safe Medication Practices Medication Error Reporting Program (USP-ISMP MERP) and the US Food and Drug Administration MedWatch; and
THEREFORE BE IT FURTHER RESOLVED that NABP review and revise, if necessary, the Model Act regarding the implementation of continuous quality improvement and peer review programs and best practice recommendations, in accordance with non-discovery provisions that allow appropriate access by the state boards of pharmacy and regulatory agencies, with the ultimate goal of enhancing patient safety and quality of care; and
THEREFORE BE IT FURTHER RESOLVED that NABP request that ISMP or other appropriate groups study the creation of a standardized approach to conduct root cause or causative factor analysis for medication errors that cause sentinel events.
(Resolution passed at the NABP 103rd Annual Meeting, Portland, OR)
