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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​  
American Association of Retired Persons, Prescription Drugs (AARP)​

Institute for Safe Medication Practices​  
Consumer Healthcare Products Association​ 
NABP Safe Pharmacy 

For reporting concerns, please contact the Oregon Board of Pharmacy.

Pharmacist/Staff Information

Oregon Patient Safety Commission​
Institute for Safe Medication Practices​ 
Compendium of Best Solutions by National Patient Safety Foundation​
U.S. Food and Drug Administration, CDER Medication Errors
Patient Safety Network, Agency for Healthcare Research and Quality​
Massachusetts Board of Registration in Pharmacy Medication Error Reduction​  
USP's medication error reporting program

National Association of Chain Drug Stores ​

University of Michigan Health System Patient Safety​ 
Joint Commission on Accreditation of Healthcare Organizations​

ISMP self-evaluation 
Error-Prone Abbreviations, Symbols, and Dose Designations ​


Prescription Error CE​