USP Quality Review

No. 67, Issued June 1999

National Coordination and Collaboration Effects Change

Since the Council's inception, it has accomplished numerous important achievements. In addition to standardizing the definition of a "medication error" and promoting the implementation of a standardized medication error outcome index, the Council has participated in the development, approval, and sponsorship of a series of recommendations to help reduce the risk of medication errors. Several nodes related to the medication use process have been addressed. Recommendations to Correct Error-Prone Aspects of Prescription Writing (September 1996) was the first and included the publication of a Dangerous Abbreviations list — abbreviations that are frequently misunderstood or have often been implicated in medication errors and should never be used.

Most recently, the Council adopted a set of recommendations aimed at establishing and reinforcing safe dispensing techniques (Figure 3). While these guidelines may represent a standard already expected and perhaps achieved by most practitioners, the practical importance of these recommendations resides in their joint endorsement by a diverse group of organizations, ranging from experts in safety issues to manufacturers of drug products to regulators. By acknowledging the importance of medication error prevention and achieving consensus through a collaborative effort by these national leading health care and consumer organizations, the recognition grows that only by adoption of a non-punitive, systems perspective can the problem of medication errors be solved.

Currently the Council is finalizing a set of recommendations addressing mechanisms to reduce medication errors related to the administration of drugs. To keep abreast of NCC MERP activities, visit its Web site at www.nccmerp.org.