USP's hospital medication error report supports key patient safety goals

December 08, 2003

New Orleans, La. Dec. 8, 2003--Data from the most recent report on medication errors compiled by the United States Pharmacopeia (USP) supports several key patient safety goals outlined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in the areas of patient identification, communication, high-alert medications, and use of infusion pumps.

JCAHO provides accreditation to U.S. hospitals and health care facilities and is working to achieve high patient safety standards in the U.S. health care system--a goal that USP is also committed to reaching in the area of medication errors.

All JCAHO-accredited hospitals and healthcare facilities are required to implement JCAHO's 2004 National Patient Safety Goals by Jan.1, 2004. The first National Patient Safety Goals were announced by JCAHO in July 2002. Each goal includes no more than two succinct, evidence-or expert-based requirements. National Patient Safety Goals and requirements are announced annually in July and take effect January 1 of the following year.

JCAHO's 2004 National Patient Safety Goals focus caregivers on a variety of patient safety issues, specifically:

  1. Improve the accuracy of patient identification;
  2. Improve the effectiveness of communication among caregivers;
  3. Improve the safety of using high-alert medications;
  4. Eliminate wrong-site, wrong-patient and wrong-procedure surgery;
  5. Improve the safety of using infusion pumps;
  6. Improve the effectiveness of clinical alarm systems; and
  7. Reduce the risk of health care acquired infections.


"This year, USP's annual MEDMARX report on U.S. hospital medication errors released data that focus attention on four of the six key JCAHO 2003 National Patient Safety Goal requirements," said Diane Cousins, R.Ph., vice president of USP's Center for the Advancement of Patient Safety (CAPS). "USP is working toward a goal we hold in common with JCAHO: ensuring that patient safety remains high on the agenda of hospitals and health care facilities. Our common vision is to achieve a hospital system where no medication errors reach or harm hospitalized patients."

Of the four JCAHO National Patient Safety Goal requirements supported by the MEDMARX data:
  1. Misidentified or "wrong patient" types of errors were seen in 4.7 percent of the 2002 database records and involved every phase of the medication use process;
  2. Communication issues combined were found to be the third leading cause of errors;
  3. About nine percent of the MEDMARX records involving errors with infusion pumps were harmful to patients; and
  4. MEDMARX Finds That High-Alert Medications Continued to Harm Patients in 2002


This year's USP MEDMARX report found that high-alert medications continued to harm hospitalized patients. Medications designated as "high-alert" tend to have a higher risk of patient injury when involved in a medication error. As in the 2001 MEDMARX data, eight of the 10 products most often involved in medication errors that caused patient harm were high-alert medications. As was the case in 2001, the eight high-alert products in the list of top 10 products harming patients represented 35.1 percent of all medication errors that caused harm to the patient in 2002.

Examples of recurring top 10 high-alert products in the MEDMARX 2002 data report that continued to cause harm to hospitalized patients through medication errors include: insulin, morphine, heparin, potassium chloride, warfarin and hydromorphone. USP calls for all high-alert medications to be packaged, stored, distributed, prescribed, dispensed and administered safely to minimize the risk of injury to patients.

"USP's data clearly demonstrate the need to improve patient safety through renewed efforts to prevent patient misidentification, miscommunication between caregivers, errors in administration of high-risk medications and infusion pump errors," said Paul M. Schyve, M.D., senior vice president, Joint Commission on Accreditation of Healthcare Organizations. "JCAHO commends USP for bringing attention to these issues. Together, USP and JCAHO--with the implementation of JCAHO's National Patient Safety Goals--hope to help health care facilities prevent potentially devastating medication errors."

USP's MEDMARX

MEDMARX is a 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 fosters a nonpunitive, interdisciplinary reporting system for medication errors and enables hospitals to implement corrective actions and track the success of internal system changes. Health care systems use MEDMARX to track and trend error data from MEDMARX- member health care facilities. This database is the largest to capture potential and actual errors before they reach the patient. Participating hospitals use these precursor events to identify and strengthen safeguards that prevent errors from reaching patients, thus providing safer patient care.

Currently, 20,000 records per month--an increase of 5,000 records per month from last year--are being entered into the MEDMARX system from more than 650 participating health care facilities across the United States. It is estimated that by the end of the third quarter of 2004, the MEDMARX database could approach one million records.
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For the full text of the JCAHO National Patient Safety Goals, please refer to the USP fact sheet JCAHO 2004 Patient Safety Goals at www.usp.org/newscenter.

For more information on errors involving high-alert medications, please refer to the USP fact sheet MEDMARX 2002 Data Raises Concerns for Hospitals and Health Care Facilities on Medication Errors Rates for High-Alert Medications at www.usp.org/newscenter.

For more information on the MEDMARX 2002 data report, which includes a special focus on seniors, please see USP's November 18, 2003 news release, available on our Web site at www.usp.org/newscenter or to receive a copy of the 2002 data report, or to request MEDMARX b-roll, send an e-mail to mediarelations@usp.org.

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 www.usp.org/e-newsroom.

US Pharmacopeia

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