USP releases first-ever case study book to advance medication error prevention

March 10, 2004

Rockville, Md., March 10, 2004 -- The United States Pharmacopeia (USP) today released Advancing Patient Safety in U.S. Hospitals: Basic Strategies for Success, a first-ever case study book featuring actual hospital medication errors and steps taken to prevent similar mistakes.

"This unique book was written to help hospitals and health care systems reduce medication errors and facilitate a culture change that embraces error reporting systems," explained Diane Cousins, R.Ph., vice president of the Center for the Advancement of Patient Safety (CAPS) at USP.

More than two dozen health care administrators and practitioners were interviewed for this book, representing large and small U.S. hospitals. Their telling accounts describe the steps they have taken to change their hospitals' cultures of blame; how they convinced staff members to report more medication errors; how error reports are analyzed to identify trends; and how their hospitals have instituted process changes to reduce medication errors.

"Without error reporting, we cannot identify and implement the system and process changes necessary to eliminate medication errors," Cousins said. "Many of the first-person accounts in this book offer situations familiar to many health care practitioners. We believe hospitals and health care institutions nationwide will find the book's information a valuable resource and tool for building a safer health care system."

In addition to first-person accounts, USP offers 10 recommendations to improve medication safety in health facilities. Among the recommendations: adopt a nonpunitive policy for reporting potential and actual medication errors; create open lines of communication among departments and disciplines; and provide incentives for participating in the medication safety reporting system.

USP operates MEDMARX, the national, Internet-accessible anonymous reporting database that hospitals and health care systems use to track and trend medication errors. Hospitals and health care systems participate in MEDMARX voluntarily. USP created MEDMARX to help health care facilities understand the causes of medication errors and the factors that contribute to them in order to improve patient care and safety.

MEDMARX helps hospitals report, understand and ultimately prevent medication errors in hospitals. The MEDMARX data report, Summary of Information Submitted to MEDMARX in the Year 2002: The Quest for Quality, provides a comprehensive analysis of 192,477 medication errors as voluntarily reported by 482 hospitals and health care facilities nationwide, including community, government and teaching institutions. MEDMARX is the nation's largest database of medication errors, containing more than 580,000 released records.

To order a copy of the book go to:

MEDIA NOTE: A media teleconference will be held on Wednesday, March 10th at 1:30 p.m. EST to discuss the case study book's findings and patient safety recommendations. To access the teleconference, dial 1-800-860-2442. Inform the operator that you are calling for the "U.S. Pharmacopeia" teleconference. To RSVP for the teleconference, send an e-mail to

For more information on MEDMARX, or to receive a copy of the 2002 data report, send an e-mail to Please also note that all hospital representatives interviewed for this book are available for comment. Contact for interview details and for a copy of the book.
USP--Advancing Public Health Since 1820 The United States Pharmacopeia (USP) is a nonprofit, nongovernmental, standard-setting organization that advances public health by ensuring the quality and consistency of medicines, promoting the safe and proper use of medications, and verifying ingredients in dietary supplements. These standards, which are recognized worldwide, are developed by a unique process of public involvement through the contributions of volunteers representing pharmacy, medicine, and other health care professions, as well as science, academia, government, the pharmaceutical industry, and consumer organizations. For more information about USP and its four public health programs, visit


Actions to Improve Medication Safety

The United States Pharmacopeia (USP) has worked with hospitals for more than 30 years to improve medication safety. This experience, combined with research and interviews conducted for Advancing Patient Safety in U.S. Hospitals: Basic Strategies for Success, has led to the following 10 recommendations for improving medication safety in hospitals and health care facilities.

1) Engage the CEO, administrators, and medical director in medication safety efforts. This involvement will help facilitate necessary culture and policy changes, helping to ensure that medication safety is a priority.

2) Adopt a nonpunitive policy for reporting potential and actual medication errors. Dissociate the performance appraisal system from the medication error reporting system. These policies build trust and eliminate the fears that prevent error reporting.

3) Provide incentives for your medication safety reporting system. Educate staff members on the importance of error reporting and institute programs that express appreciation for reporting efforts.

4) Create a multidisciplinary committee that meets regularly to examine medication error trends and suggest process improvements. Error analysis should be integrated in order to identify better practices and solutions.

5) Create open lines of communication among departments and disciplines. Staff members must feel comfortable discussing and resolving issues with pharmacists, physicians, nurses, and others.

6) Provide multiple methods for staff members to report errors and suggest improvements for safe medication use. Telephone hotlines and regular hospital rounds by administrators can be an effective means for staff members to raise safety issues.

7) Share information obtained from medication error reports with staff members, at least in aggregate form. By sharing information, the importance of the overall patient safety effort increases.

8) Standardize and simplify procedures and protocols. Be careful to balance process simplification with double checks for critical procedures.

9) Minimize distractions while nurses are preparing or administering medications. Establish separate rooms for nurses to prepare medications or create a system to take phone messages for nurses on medication rounds.

10) Work to change state laws where necessary. Work with legislators, task forces and others to develop guidelines compatible with a nonpunitive reporting environment.

US Pharmacopeia

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