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Patient Safety and Medication Error Reduction
Adopted October 2008
Beginning in 2000, in response to the number of medication errors and medication distribution issues, state boards of pharmacy across the country began to convene committees and work groups to research and report back to the boards about ways to reduce medication errors. In response to the Oregon Board of Pharmacy’s interest in promoting an awareness of and ultimately a decrease in medication errors, the Board convened its Medication Error Reduction – Patient Safety Research Council.
 
The charge of Oregon’s 12-member multi-disciplinary Research Council was to investigate procedures designed to reduce medication errors and evaluate the role the Board currently plays in supporting medication error reduction efforts. The Research Council was also asked to recommend measures the Board could take to improve patient safety through medication error reduction programs in the state. The Research Council has developed a document that reflects optimum standards for providing patient care in today’s pharmacies. While the document is not intended to be a comprehensive list of goals that are completely achievable on a continual basis, it does suggest a number of specific procedures that can be implemented in pharmacy practice settings in an effort to enhance existing quality improvement programs.  This list is not exclusive of other improvements and may be supplemented by the Board from time to time.
 
Optimizing Patient Safety and Reducing Medication Errors, the 23-point document developed by the Research Council, was based on a review of current literature and work done in other states. The recommendations have been modified and edited specifically for use in Oregon pharmacies. The Board would like to acknowledge the work done by the National Association of Boards of Pharmacy’s 2007-08 Task Force on Continuous Quality Improvement, Peer Review, and Inspecting for Patient Safety, the Massachusetts Board of Registration in Pharmacy, and The Institute for Safe Medication Practices. 
 


The Oregon Board of Pharmacy expects all licensees to engage in practices that assure patient safety.  All pharmacies should take proactive measures to prevent errors, and adopt a safety culture which allows for sharing of information to promote best practices.  Links to resources to reduce medication errors and improve patient safety can be found below.
 
Safety culture is the enduring value and priority placed on worker and public safety by everyone in every group at every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety, act to preserve, enhance and communicate safety concerns, strive to actively learn, adapt, and modify (both individual and organizational) behavior based on lessons learned from mistakes, and be rewarded in a manner consistent with these values.*
 
*Source: Federal Aviation Administration Report 2002(5)

Patient/Consumer Information
Patient Safety
Oregon Patient Safety Commission http://oregonpatientsafety.org/
 
American Association of Retired Persons, Prescription Drugs: Your Personal Guide to Prescription Drugs http://www.aarp.org/health/rx_drugs/
 
Institute of Medicine Fact Sheet: What you can do to avoid medication errors http://www.iom.edu/CMS/3809/22526/35939/35945.aspx
 
Institute for Safe Medication Practices http://www.ismp.org/ 
 
Consumer Healthcare Products Association http://www.chpa.org/
 
Safe Medication, http://www.safemedication.com/
 
For reporting concerns, please contact the Oregon Board of Pharmacy.
 
           

Pharmacist/Staff Information
GENERAL



Oregon Patient Safety Commission http://oregonpatientsafety.org/
 
Institute for Safe Medication Practices http://www.ismp.org/
 
The Just Culture Community, http://www.justculture.org/
 
Institute of Medicine Reports,http://www.iom.edu
 
Compendium of Best Solutions by National Patient Safety Foundation http://www.npsf.org/ 
 
U.S. Food and Drug Administration, CDER Medication Errors site: http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/default.htm
 
Patient Safety Network, Agency for Healthcare Research and Quality, http://psnet.ahrq.gov/ 
 
Massachusetts Board of Registration in Pharmacy Medication Error Reduction site: http://www.mass.gov/eohhs/provider/licensing/occupational/pharmacy/medication-error-prev/
 
USP's medication error reporting program,

http://www.usp.org/sites/default/files/usp_pdf/EN/aboutUSP/pressRoom/medicationErrorReportingPrograms.pdf                                             

COMMUNITY PHARMACY PRACTICE
 
National Association of Chain Drug Stores -  http://www.nacdsfoundation.org/HOME.aspx

INSTITUTIONAL PHARMACY PRACTICE
 
University of Michigan Health System Patient Safety - http://www.uofmhealth.org/michigan-model-medical-malpractice-and-patient-safety-umhs
 
Florida Hospital Association Patient Safety Toolkit http://www.fahq.org/resources/index.html
 
Joint Commission on Accreditation of Healthcare Organizations, Patient Safety http://www.jointcommission.org/standards_information/npsgs.aspx 
 

CE RESOURCES
 
ISMP
ISMP, http://www.ismp.org/ for the self-evaluation toolkit.  The quarterly action agenda is full of free CE Click on http://www.ismp.org/Newsletters/acutecare/actionagendas.asp
 
List of Error-Prone Abbreviations, Symbols, and Dose Designations
http://www.ismp.org/tools/errorproneabbreviations.pdf
Toolkit of resource materials: www.ismp.org/tools/abbreviations
 
RXSchool
www.RXschool.com
 
PowerPak
PowerPak.com http://www.powerpak.com/
Prescription Error CE at: http://www.powerpak.com/index.asp?page=courses/105114/disclaimer.htm&lsn_id=105114
 
ACPE
http://www.acpe-accredit.org/pharmacists/programs.asp
 
Note: A Google search of “medication errors continuing education” will come up with an unlimited number of medication error CEs.