Meeting: October 14, 2008

Meeting Date October 14, 2008 (8:42am – 1:52pm)

Member Organizations (Present at meeting in Bold)

Discussion Items

1. NQF Common Formats Expert Panel – The goal is encompassing all patient safety activities and will begin with the hospital inpatient setting. The intention is for the document to be dynamic. The group has held two teleconferences. A framework document is under development. Three generic "forms" have been developed: patient, event, follow–up. Nine Event Specific Forms provide for reporting of Medication Errors, Falls, etc. Membership expansion efforts will focus on engaging physician input as currently no organization is represented by a physician and only one physician organization is a member.
2. The Council's Drug Samples Recommendations regarding manufacturer packaging and labeling are in concert with FDA Regulation.
3. Drug Suffixes Survey – A preliminary analysis of responses was provided. The survey was open to practitioners and was distributed by Council members from April to June 2008. Responses were received from 5,697 individuals. Respondents exhibited varying levels of expertise in interpreting suffixes. Over 60% of respondents are aware of medication errors associated with the use of suffixes in drug names.
4. ISMP's Consumer Website <www.consumermedsafety.org> will be live by the end of the month.
5. Pediatric Medication Safety
   1. Presentation – handheld Pediatric Dosing Device
   2. Report of workgroup on environmental scan of activities of stakeholder organizations
6. Ongoing discussion of Medication Error Rates vs. Medication Error Reporting Rates

Action Items

1. Approval of June meeting summary
2. Approval of agenda
3. Membership of the following organizations were renewed for two-year terms:
   1. American Society for HealthCare Risk Management
   2. American Society of Consultant Pharmacists
   3. Department of Defense
   4. Institute for Healthcare Improvement
   5. Department of Veterans Affairs
   6. National Alliance of State Pharmacy Associations
   7. Institute for Safe Medication Practices
   8. National Council on Patient Information & Education
4. Organizations were encouraged to ensure the assignment of alternatives. Membership outreach will be made to a number of medical organizations: AAFP; AAP; ABMS; ACPF; AGS; SHM and individual patient safety officers. In addition outreach will be made to their national organization.
5. Future Council actions regarding Drug Suffixes Survey
   1. Clarification of authorship for a manuscript
   2. Development of an outline and timeline
   3. Updating and copyrighting of slides
   4. Forwarding of the information to The Joint Commission for consideration by the Sentinel Event Advisory Committee
   5. Exploration of publishing opportunity
   6. A press release will be developed for sharing by the members in internal communication organs
6. Future Council actions: Pediatric Medication Safety – Information will be drafted for the Council's website as a cover for pediatric medication safety resources
7. The Bar Coding Subcommittee will shepherd an implementation survey in spring, 2009
8. A letter of congratulations will be forwarded to Michael Cohen on his receipt of the Individual Eisenberg Award

Next Meeting Date

February 3, 2009 (8:30am – 3:00pm)

Actions/Decisions are those of the Council as a whole and may not reflect the views/positions of individual member organizations.