1 Medication Error Reduction Plan Program - Patientsafetycouncil.org

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Office of Inspector General Report • 14% of events are reported • Reason – don’t see the outcome as an error • 11% of events that led to death reported • Medication = 38% of adverse events • 13% reported • Changes in mental status (delirium); excessive bleeding, hypoglycemic event Can Medication Safety System Vulnerabilities be identified proactively and objectively? Medication Safety Event Tracking Med SET Launched September 2011 6
Med SET • Objectives/Goals: • Collect, quantify, and analyze medication safety data. • Goals: • Identify medication safety system vulnerabilities and their trends • Use Med SET data to inform and educate internal and external providers on medication safety issues Med SET • Data extracted from Statement of Deficiencies • Long term care and hospitals • Used MERP defined systems or procedures and expanded - internal use only • 12 categories with 85 sub-categories • Compare different facility types • Present level of harm MERP 1. Prescribing 2. Prescription order communication 3. Product labeling 4. Packaging and nomenclature 5. Compounding 6. Dispensing 7. Distribution 8. Administration 9. Education 10.Monitoring 11.Use Med SET 1. Prescribing 2. Prescription order communication 3. Product labeling, packaging and nomenclature 4. Compounding 5. Dispensing 6. Distribution 7. Administration 8. Monitoring 9. Competency 10.Use 11.Technology 12.Transitions in care 7
Page 1 and 2: Medication Error Reduction Plan Pro
Page 3 and 4: Issues: • Automated Dispensing Ca
Page 5: Department of Health and Human Serv
Page 9: Med SET: Next Steps • Seek input

1 Medication Error Reduction Plan Program - Patientsafetycouncil.org

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