Preventing Medication Errors: a Summary

Purpose: To summarize key recommendations and supporting evidence from the most recent Institute of Medicine (IOM) report, Preventing Medication Errors.

Summary: Starting in 2000, IOM reports brought the problem of medical safety into public awareness and made four major points: errors are common and costly, systems cause errors, errors can be prevented and safety can be improved, and medication-related adverse events are the single leading cause of injury. The most recent report is an attempt to think about what needs to be done to reach the next level of medication safety. Some have had difficulty implementing these recommendations, but these challenges can be overcome by learning from these experiences. Evidence supporting the recommendations made in this report includes research on computerized prescriber order entry (renal insufficiency geriatric patients, meta-analysis, unintended consequences, pediatric transfer patients); intravenous infusion safety systems; and dispensing errors and bar-coding.

Conclusion: Preventing Medication Errors lays out a blueprint for change in medication safety. The report makes clear that providers have m any opportunities to improve. Technologies, such as computerized order entry, bar-coding and smart pumps and computerized ADE monitoring, will undoubtedly play a key role, and institutions should be thinking seriously about implementing a number of these. The report also emphasizes how essential a culture change, combined with well-designed technologies, will be necessary to achieve the next level of safety called for in the IOM report.