Rockville, October 14-15, 1999

Format
Rockville

NCC MERP Meeting Summary

October 14, 1999

Day One

Council delegates present:

  • Deborah Nadzam, Chairperson, (Cleveland Clinic)
  • Jerry Phillips Vice Chairperson (FDA)
  • Diane Cousins, Secretary (USP)
  • Joseph Cranston (AMA)
  • Alice Till (GPIA)
  • Jeff Ramirez (Dept of VA) Jerry Phillips Vice Chairperson (FDA)
  • Barbara Newman (NCSBN)
  • Rita Munley Gallagher (ANA)
  • John Combes (AHA)
  • Stacy Fitzsimmons (PHRMA)

Alternates present:

  • John Santell (ASHP)

Alternates that attended along with their delegates:

  • Shawn Becker (USP)
  • Mary Gross (FDA)
  • Herb Carlin (GPIA)

Delegates absent:

  • Michael Cohen (ISMP)
  • William Ellis (APhA)
  • John Kessler (ex officio)
  • Janet Myder (AHCA) Joseph Deffenbaugh (ASHP)
  • Linda Hanold (JCAHO)
  • Andrew Smith (AARP)
  • Jon May (NABP)

Observers present:

  • Judy McMeekin (USP)
  • Fay Menacker (USP)
  • Robert Danaht Mark Feld, M.D. (StartPoint Health Care)
  • Elizabeth Cowley (USP)

Deborah Nadzam called the meeting to order at 1:30 PM. Dr. Nadzam welcomed the members and observers, who were asked to introduce themselves and acknowledge their affiliations.
The Chairperson opened the floor for any added agenda items. There being none, Dr. Nadzam requested the activity updates and member discussions to begin.

Activities Update

  • NCSBN(Barbara Newman) - The NCSBN is currently undergoing reorganization with a new executive director. Submitted complaints are being evaluated and an analysis of those complaints indicates approximately 42 percent involve medication errors. One goal is the ability to discriminate between systems structure that may precipitate an error, versus the individual accountability on it. Mike Cohen was present at the September board meeting to talk about creative ways of packaging.
  • GPIA(Alice Till) - Michael Cohen gave a talk on medication errors that was most informative. Nothing else to report at this time.
  • AHA (John Combes) - A copy of the four-part article on medical errors that appeared in the Philadelphia Inquirer was passed around for the Council's review. The bankruptcy of a Pennsylvania hospital allowed Andrea Rolland, a journalist, to obtain the records that revealed approximately 450 cases of medical error that were not involved in law suits. Many of the cases involved medication errors. The obvious question that was raised in the articles was how to punish people who commit these kinds of errors. We prepared an op-ed response to the Philadelphia Inquirer article which focused on the need to change a phrase used throughout the piece "the culture of denial" which has its roots in the culture of blame. Subsequent to this article the Hospital Association of Pennsylvania held two programs featuring Mike Cohen. This started major initiatives within the state beginning with a summit of the pharmaceutical industry and the regulatory bodies within the state, the medical society, and the insurers. The AHA is working with their board to come out with a major statement on what hospitals' accountabilities are.
  • VA (Jeff Ramirez) - Our biggest VA quality center focusing on the reduction of adverse drug events and an educational process to eradicate such errors is in the New England area. Over time the VA will publish a set of best practices so that others can adopt them. The Office of the Medical Inspector has a contract with a consulting firm in the Arlington area to look at the overall framework of ADE reporting with many of the same goals that were discussed with USP and FDA on electronic reporting. That process should take approximately nine months. It might even result in the revamping of existing software relating to the documentation of medications. The VA is getting ready to release software to document medications at the bedside using barcodes. The first 22 sites began implementation October 1st and will be going out in four phases, hopefully, completing the whole project by the end of April 2000.
  • PHRMA (Stacey Fitzsimmons) - PHRMA is very interested in the whole safety-risk benefit ratio associated with drugs, and looking at the role the stakeholders have, the sources of medication error for physicians and nurses, and the role of the media. PHRMA is working with the FDA on a paperless labeling initiative to submit electronically NDA's and ANDA's by the year 2002. Issues to be overcome are the labeling and the package inserts.
  • FDA (Jerry Phillips) -NCC MERP got recognition at a recent conference Mr. Phillips attended in Baltimore. He was in a work group dealing with safer administration techniques. The NCC MERP had just completed recommendations on administration and Mr. Phillips was able to get those included in the final conference recommendations. Mr. Phillips provided an update on the guidance document for equivalence rating. Considerable comment was received on this issue but unfortunately the final comments have not been incorporated into the revisions document as yet. The Office of Post-marketing Drug Risk Assessment has expanded into the pre-marketing review of trade names. The FDA's previous mechanisms of labeling and nomenclature have been turned over to this office where full time employees will be looking at trade names as they come in the door.
  • ASHP (John Santell) - The Research and Education Foundation Board is meeting to decide funding a multimillion-dollar research project designed to create and test a fail-safe medication use system. Also, in the process is a revision and re-publishing of a 1998 diagram differentiating medication errors, medication misadventures, adverse drug events, and adverse drug reactions. Medication errors and misadventures continue to be presented at the ASHP mid-year and annual meetings. ASHP is actively involved in the Harvard Executive Session, which focuses on medication errors and misadventures. The most recent meeting concerned packaging and labeling. ASHP is working with the National Patient Safety Foundation on its report on a major initiative "Safe Use Of Pharmaceuticals As A National Health Policy" where an initiative is to have infomercials regarding questions consumers should ask about their medications aired on TV.
  • AMA (Joseph Cranston) - AMA and Intel announced a merger whereby they are going to try to give all physicians digitized signatures so that they can begin to prescribe and communicate electronically. This should be a significant event. The National Patient Safety Foundation is in the process of developing a Phase II action plan that is a result of the conference mentioned by John Santell. NPSF is still seeking an Executive Director.
  • USP (Diane Cousins, Secretary) - NCC MERP has hit the international realm with a request from Ireland to secure a copy of the taxonomy. They were interested in studying health care professionals' views on medication error reporting. Ms. Cousins reported that as follow up to the last meeting, the FIP, Federation of International Pharmacists, has adopted many of the recommendations that the NCC published and they were pretty much verbatim. There were a few changes and some of them made good sense, especially for the international arena. This is another international adoption of the Councils recommendations which is very gratifying. Also, a pharmacy department from St. Joseph's Hospital in Pontiac, Michigan, put out our recommendations on error-prone aspects for medication order writing to their staff and is asking that the recommendations be adopted as part of their policy. Someone in Maine working on the Maine Pharmacy Act Review requested a copy of the taxonomy in determining whether or not to require pharmacists to maintain incident logs or participate in some type of reporting.

    From USP's standpoint Ms. Cousins reported that the United States Adoptive Names Council is considering a change to the names for Amrione and Amiodarone, based on medication errors that have been received at USP where these products have been mixed up. Inamerone and Camiodarone would replace the names. Chuck Barnstein from USP is observing today in an effort to obtain the NCC MERP members comments on the issue of the name change for these products. After surveying several different disciplines (copies of the survey were made available to the membership), USP is now submitting a manuscript for publication. What USP would like to hear from health care professionals is whether these proposed name changes are something that should be adopted. Any and all promotion and distribution help would be appreciated. Ms. Cousins asked the delegates to raise any questions at this point so that Mr. Barnstein could respond. A second survey was distributed to health care professionals (ASHP members), regarding neuromuscular blocking agents. In-depthrecommendations proposed that appear to meet with the approval of health care professionals include: changes to labeling and packaging - a warning on the cap that this is a paralyzing agent, the fact that the different concentrations should be distinguishable one from another. The less popular recommendation was the addition of an auxiliary label to distinguish the products one from another. USP will be surveying nurses through the International Journal of Trauma Nursing in Oct/Nov issue and are also talking with JAMA to get a survey in that journal to get feedback from physicians. The USP standard for potassium chloride will probably be rewritten to include a clear plastic cap, as well as the black cap. Additionally, as a result of the Council's recommendations on packaging and labeling for regulators and standard setters, USP is revisiting the flip-off caps on injectables an is now considering limiting its use to warnings only as an USP standard. This standard was posted in the May/June 1999 issue of Pharmacopeial Forum and USP is waiting for industry comment on this. However, the subcommittee was favorable toward restricting the use of these caps for warnings only and the next step is to survey practitioners. USP Quality Review has been published that addresses the issue of Celexa, Celebrex, and Cerebyx name confusion.

  • Rita Munley Gallagher (ANA) - ANA has engaged Lucian Leape to present the keynote at the June convention in Indianapolis. The other activity that is really tangential to the work of the Council is that ANA is embarking on a significant safe needles campaign for practitioners and it has been very successful so far. ANA continues its coalitions that most of the Council is also engaged in.
  • Deborah Nadzam (Cleveland Clinic) - As a health system provider perspective, Ms. Nadzam informed the Council that they are in the process of implementing MedMARxTM across all of our hospitals at the Cleveland Clinics. We are holding an all-day workshop on ADE's, which is the program put on by the Advisory Board. Approximately, 100 physicians, pharmacists and nurses will be attending. The quality institute invited Bob Galvin, M.D., who is the medical director of GE, to talk with the group about what he valued in a provider
    organization to determine quality. Dr. Galvin stated right away that culture is first and second is that the organization is doing something about medication errors.

Verbal Orders

Diane Cousins, sitting in for John Kessler, reported on the draft recommendations regarding verbal orders that should be considered by the Council. These include:

  • Standardized prescription forms Preference for written or electronic orders Clear communication without abbreviations
  • Repetition of verbal orders to prescribers, may or may not include spelling
  • Clarification of purpose of drug
  • Pharmacists faxing confirmed prescriptions to prescribers
  • Prescriptions to be recorded
  • Considerable discussion ensued surrounding the issue of verbal orders and the Council members
  • discussed each specific recommendation in order to determine the best wording. A team will take all the discussion points and clarify/organize these for the next meeting.

ACTION ITEM: Alice Till will take the lead and work with Jerry Phillips, Monica Berry, and John Santell to organize comments on verbal order recommendations for the next meeting.

Automation in the Medication Use Process

Results of the subgroup were distributed to the delegates. The delegates determined that the results of the subgroup are fairly generic and needed more detail. Computerized entry of prescriptions is the preferred method of prescription writing. What is the next step? ASCP has come out with a paper on automation and the NABP has their model pharmacy practice act. Ken Barker is an expert in this field and should be consulted. There is no industry-wide system in effect. Council needs to come up with an intelligible and comprehensive system that addresses this issue. Council discussed the possibility of creating an RFP for the NPSF to conduct research on automation. Also discussed was the possibility of talking with the Computerized Patient Record Institute (CPRI). However, it was felt that this group might not have picked up on the medication-related aspects as of yet. It was suggested that the Council contact the Health Information Management-systems Society (HIMS) to see what they are doing regarding automation.

ACTION ITEM: Same subgroup-Deborah Nadzam, John Combes, Diane Cousins, and Joe Cranston will pull together information and comments for potential white paper on this subject.

Presentation

Dr. Mark Feld, StartPoint Healthcare, thanked the Council for the opportunity to talk about how to improve communication between the various facets of the health care industry. He stressed that communication is at the heart of most quality improvement projects. Prescription writing is communication and the illegibility of prescriptions is extremely inefficient, for both pharmacists and prescribes. He stated that it is necessary to take all the recommendations from groups such as USP and the ISMP concerning look-a-like medicines and sound-a-like medicines, the improper use of zeros and improper use of decimal points, improper abbreviations, possibly writing down the purpose of the medication and put it into a framework that a prescriber can use to assure clear communication. The simple use of a palm-pilot with a pre-loaded medications database or some other such small entry device that is portable, that can be taken into a doctor's examination room, together with the use of a dedication prescription printer, is what's needed.

Dr. Feld also advocated the induction of bar coding as a prescription record. He advocated a new minimum standard in prescription writing. Dr. Feld asked the Council to generate a list of medications to be used in his product. Dr. Nadzam reminded Dr. Feld that was beyond the scope of the Council but they would discuss.

ACTION ITEM: Council will respond in writing to Dr. Feld's request for a list of medications sanctioned by the NCC MERP for his product. The Council will send Dr. Feld the prescription writing recommendations and the list of look-alike, sound-alike drugs.

NCC MERP Medication Error Index for Categorizing Errors

Barbara Newman (NCSBN)

Barbara Newman explained the homework assignment regarding the Medication Error Index. Two algorithms to clarify or streamline medication errors were to be applied to two case studies. There exists a need to clarify the index and possibly add a second page, including a flow chart or decision tree to assist users. The definition of "intervention" has to be revised.

After a preview of Day 2's agenda, it was moved and seconded that the meeting be adjourned. The motion carried and the meeting concluded at 4:20 PM.

October 15, 1999

Day Two

Council delegates present:

  • Deborah Nadzam Chairperson, (Cleveland Clinic)
  • Jerry Phillips Vice Chairperson (FDA)
  • Diane Cousins, Secretary (USP)
  • Joseph Cranston (AMA)
  • Alice Till (GPIA)
  • Jeff Ramirez (Dept of VA)
  • William Ellis (APhA) Barbara Newman (NCSBN)
  • Rita Munley Gallagher (ANA)
  • John Combes (AHA)
  • Stacy Fitzsimmons (PHRMA)
  • Andrew Smith (AARP) Monica Berry (ASHRM)

Alternates present:

  • John Santell (ASHP)
  • Judy Smetzer (ISMP)

Alternates that attended along with their delegates:

  • Shawn Becker (USP)
  • Mary Gross (FDA)
  • Herb Carlin (GPIA)
  • Melissa Stegun (APhA)

Delegates absent:

  • Michael Cohen (ISMP)
  • Linda Hanold (JCAHO)
  • John Kessler (ex officio)
  • Joseph Deffenbaugh (ASHP)
  • Jon May (NABP)
  • Janet Myder (AHCA)

Observers present:

  • Steve Wickizer (AHCPR)
  • Judy McMeekin (USP)
  • Elizabeth Cowley (USP)
  • Sue Zmuda (USP) Ken Alexander (USP)
  • Fay Menacker (USP)
  • Sharon Bohrer (USP)
  • Linda Kim (USP)

Deborah Nadzam called the meeting to order at 8:35 A.M. The first order of business was a phone presentation, via conference call, by Laura Berberian, Vice President, Clinical Affairs, Cardinal Information Corporation.

Presentation:

An Automated Program for Adverse Drug Event Reporting and Monitoring Using the NCC MERP Taxonomy.

Laura Berberian, Vice President of Clinical Affairs for the Cardinal Information Corporation

Ms. Berberian thanked the Council for the opportunity to speak. Handouts were distributed. She explained that their program processes electronically available information on a real time basis from any of their hospitals information systems, such as patient demographics and electronically available pharmacy and laboratory information. They will also take information that may not be readily available from the hospitals such as cost data associated with an adverse drug event and merging it into what is called an alert engine. Hospitals will actually be able to create rules specific to the hospital, such as a potassium level greater than 5.5 would warn the nurse about a possible problem with the dosage. Messages can be automatically sent to a physician if the rule states that over a certain level a physician must be alerted, but the idea is that the hospital can set their own rules. The alerts can be sent in whatever manner the hospitals prefers. Our system allows for a spontaneous reporting piece and the ability to do retrospective reporting. It can be used for quality improvement processes. Hospitals are requesting that with all this internal data being collected that they want to be able to electronically record the information in a standardized fashion. CIC is interested in using the NCC MERP taxonomy for medication error reporting. Any changes in the NCC MERP taxonomy would be reflected in the software. They want to have a multidisciplinary approach to this system. CIC wants to improve patient care and implement a process for change. A consultant brought to the attention of CIC that a taxonomy was being used in the studies done at a Boston hospital. CIC may be out with an alpha product next year so they would like to gain access to the NCC taxonomy now to include in their product. Feedback could be provided to the NCC MERP as long as the Cardinal hospitals are kept confidential. CIC is talking with USP about its MedMARx Program.

Ensuing discussion centered on how the NCC MERP taxonomy should be used by third parties and the possible opportunities for revenue generation for NCC MERP which lead right into the next agenda item.

Opportunities for Revenue Generation by Licensing the NCC MERP Taxonomy for Commercial Use

Ken Alexander from the USP legal staff was invited to assist with these discussions. Diane Cousins recused herself from the discussions because of USP negotiations with CIC regarding MedMARxTM. A summary of the Steering Committee meeting on this issue was provided for the Council members. Several issues were discussed, including:

  • Whether or not to engage in licensing agreements
  • Whether or not to charge fees for the taxonomy
  • Whether or not to incorporate

A debate ensued about the idea of a group using the taxonomy in a commercial venture and making considerable money off of the taxonomy versus the use of others to develop a standard taxonomy for medication error reporting. This situation might result in incorporation with its inherent risks but would also produce licensing fees. The face of the NCC could change from being a National Council with an emphasis on education and patient care to that of a vendor. Ken Alexander explained the issues surrounding the Council becoming incorporated. Even without incorporation, the Council can charge a fee to anyone as long as there is an established criteria upon which charges are set. The Council either has to incorporate or enter into some kind of agreement with a member organization like USP, AHA, or some other member organization to act as a custodian for those charges. It then becomes a much more complicated process. When you get into the license arena it becomes problematic if somebody were to violate the terms of the license. There is risk involved with incorporating. After incorporation the NCC MERP would become a legal entity and cannot just dissolve. The NCC MERP would need a constitution and by-laws, annual meetings, tax returns, etc., if it wants to incorporate. Mr. Alexander discussed the issues surrounding copyright versus licensing. You cannot take someone's copyrighted work and put it into a commercial product.

Several Council members were concerned about the possibility of commercial organizations using the taxonomy and showing this as an endorsement of its product. If this is what the organizations are trying to do it seems that the NCC MERP should get reimbursement for that endorsement. The discussions continued around all the issues involved with licensing, licensing and charging, and incorporating NCC MERP. A motion was put on the table that NCC MERP engage in licensing agreements with charge for commercial usage of the taxonomy. This motion was seconded and no further discussions were forthcoming. The motion carried with five delegates in agreement and four opposed. Alice Till posed an additional question regarding the legal implications associated with the motion that was just approved. Ms. Till made it clear that if the GPIA could be held accountable for any license agreements and fees then her organization would have to withdraw from the NCC MERP. According to Mr. Alexander the NCC MERP would be entering into a legal agreement and while unlikely, liability could evolve down to the individual NCC MERP members.

A motion was made and seconded to reconsider the vote that allows the NCC MERP to engage in licensing agreements with a charge for commercial usage of the taxonomy. This motion carried. The Chairperson restated the original motion "the NCC MERP can engage in licensing agreements with charge for commercial usage of the taxonomy, and called for agreement or opposition. The motion failed.

A motion was made to send a letter to Cardinal Information Corporation indicating that they may use the NCC MERP taxonomy in accordance with the copyright statement. This motion was amended to include: "The taxonomy may not be modified, altered, abstracted, or otherwise changed, except to reflect changes provided to you by NCC MERP. The attribution should state Taxonomy of Medication Errors © 1998 National Coordinating Council for Medication Error Reporting and Prevention. All rights reserved. Used with permission." The Steering Committee voted to send a letter to CIC granting permission for them to use the taxonomy in accordance with the copyright, including the statement of attribution as presented above. The motion was seconded and carried.

ACTION ITEM: Do a literature search to make sure that no other taxonomy exist for medication errors.

ACTION ITEM: Diane Cousins will draft a letter to Cardinal Information Corporation granting permission for them to use the taxonomy in accordance with the copyright statement including a statement of NCC MERP attribution. This drafted letter will be sent to all members for final approval.

The larger issue of whether the Council will incorporate, or not, will be discussed at a future meeting.

Guest Presentations:

Measures of Comparison for National Benchmarking: A Researcher's Perspective

David Bates, M.D.

Brigham and Womens Hospital

Dr. Bates shed light on measures of comparison for national benchmarking. He spoke briefly about definitions, then delved into his research on prevention study and adverse drug events outside the hospital, mainly in nursing homes, outpatient chemotherapy, etc. His work has uncovered a public relations phenomenon that blames errors on bad doctors, not on bad procedures. Dr. Bates believes the most important cause of error is faulty systems or designs.
His recommendations include:

  • Adopt physician order-entry systems
  • Bar-code medications
  • Develop systems for reporting ADEs Use unit-dose medication distribution Implement pharmaceutical care programs Have pharmacists review orders
  • View medication errors as system failures and seek system solutions to prevent them

Dr. Bates also made suggestions for medication error reporting programs and noted that USP's MedMARx Program was a move in the right direction with regard to non-punitive reporting systems. His suggestions for the NCC MERP include:

  • Standardization of terminology and definitions
  • Continue to build public awareness of the problem and channel on areas that will make a difference
  • Continue promotion of national reporting/lobbying for support for use of current data and anonymous reporting
  • More funds to study issues especially outside of the hospital setting (out-patient, long-term care, home care)
  • Need prevention studies
  • Lobbying for beneficial regulation-hospital national reporting computer systems, Prescription Order Entry
  • HCFA regulations
  • FDA-redirection of current resources
  • Consider calling for new organization to monitor safety of medications after release
  • Promote use of interventions documented to work-POE, pharmacists in ICU's, and others

Dr. Bates noted that he has three problems with the medication error definition adopted by the Council. The first issue with the definition is the word preventable. Dr. Bates group has taken the position that any time there is an error in the process that it is potentially preventable. The second issue is that the word event is included in the Council's definition and in the research arena an event means that something bad actually happened to the patient. In Dr. Bates opinion an error is an error even if nothing bad happened. Thirdly, the issue of causing or leading to appropriate medication use or patient harm is not agreeable to Dr. Bates. He thinks that it is an error even if there was no potential for patient harm.
Dr. Bates covered the number of deaths associated with drug ADE's and that there is a definite need for better information. He also covered the costs associated with this problem and mentioned that there is still a culture that reacts in a punitive manner toward those that report medication errors. Dr. Bates discussed error rates and what denominators he has seen used in the facilities that they studied. Dr. Bates also made mention that he was encouraged by the work being done by the Council and was pleased to have been invited to present his findings.

Surveillance of Nosocomial Infections - The NNIS Experience

Robert P. Gaynes, M.D.

Hospital Infections Program

Center for Disease Control

Dr. Gaynes presented, via teleconference, the CDC's system for collecting information, aggregating the data and benchmarking. He started out by identifying the scope and magnitude of nosocomial infections in the United States. He explained the CDC definition of surveillance and noted that surveillance is ongoing. Dr. Gaynes feels that there is a big difference in the data collection burden between a research study and surveillance. He notes that this is where the word ongoing has the most striking value, which is that you really have to recognize how much data you are going to collect forever. Dr. Gaynes described the SENIC study, which is the Study Efficacy of Nosocomial Infection Control. This began in the 70's and was published in 1980. The purpose was to answer a very simple question "Does infection control really control infection." When hospitals began infection control programs many question arose as to how effective they were. It was necessary to find out what the critical needs of this type of program were in order to lower infection rates. The SENIC study took 338 hospitals (a true probability sample of US hospitals) and trained an army (50 data abstractors) to go into these hospitals as teams and review 1000 patient records in each hospital. Simultaneous to that review of records they also evaluated various aspects of the infection surveillance and control programs. They looked at what they actually did to control infection. But there are several important points that the SENIC study found that Dr. Gaynes feels are still relevant. The first is that it was very clear in the analysis that the hospitals only had surveillance and really didn't have much in the way of prevention and control aspects to their program. It also found that hospitals that only had prevention and control aspects of their program and no surveillance were not the ones with the lowest rates. The analysis determined that you needed to have both. Simply said, you can't just do bean counting and not do anything with the data, nor can you let the medical literature tell you what policies to develop. You've got to count your own problems. The second important issue is that it's the only study that was as scientifically sound as it was.

Dr. Gaynes described the mission of the NNIS system as a prevention tool to reduce nosocomial infections, to provide quality data, and to monitor temporal trends in nosocomial infections, infection rates, and antimicrobial resistance in the US. He made a point that you must define what you are looking for and you cannot just write definitions and expect people to understand their meaning. Standardization requires training of those who collect the data. Studies show that medical record abstractors perform poorly in case-finding of nosocomial infections whereas infection control practitioners find. If the numerator is bad it will reflect badly on your data.
Dr. Gaynes covered the following issues:

  • Nosocomial infection case-finding
  • Surveillance of nosocomial infections and the importance of risk adjustment
  • Definition of site-specific device-associated rates
  • Infection rates in ICU's
  • Changes in utilization of NNIS surveillance components
  • Number of hospitals participating in NNIS Comparison of nosocomial infection rates
  • Limitations to interhospital comparisons of nosocomial infection rates

Dr. Gaynes concluded his presentation with a discussion of the challenges for the future in comparison of nosocomial infection rates. He stressed that what you really have to focus on is the people doing hands on patient care and not the payors and regulators.
Council members, in response to Dr. Gaynes presentation, posed numerous questions.

State Board Disciplinary Actions on Medication Errors

Judy Smetzer-ISMP

Ms. Smetzer agreed to offer up her time and present this topic at the next meeting.

NCC MERP Medication Error Index for Categorizing Errors-Reconsideration of definitions and areas for clarification

Barbara Newman - NCSBN

The homework assignment was addressed by the membership. The cases were reviewed individually. Several members noted that the definition of harm needed clarification. The concept of whether the error reached the patient or not was discussed. Depending on how this is interpreted can lead the practitioner to chose a category B, C, or D. It was recommended that the definition of harm should be placed on the back of the actual severity report for quick reference. Life threatening event may need to be clarified or defined. The members were confused as to whether they were using the original index or the new proposed language. It may not be necessary to change the language but alter it to reflect some type of clarity.
It was discussed that the use of examples would be beneficial in determining the appropriate category. The members liked using the algorithms. It was determined that the subcommittee would regroup and add Rita Munley Gallagher, and several USP staff members to lead this discussion.

ACTION ITEM: Index subcommittee, including Linda Hanold, Barbara Newman, Jon May, Judy Smetzer, John Combes, Rita Munley Gallagher, and USP staff will regroup and present their findings at the next meeting.

Dr. Nadzam summarized the activities of the NCC MERP over the past two days as follows:

  • Verbal order recommendations were discussed and now the subcommittee will tackle the job of cleaning up the recommendations and reporting back to the group
  • Subcommittee on automation took a first crack at defining the scope of the problem. It was determined that fact gathering was necessary in order to make sense of this issue
  • Dr. Feld presented a hand-held prescription writing tool and the Council will respond in writing
  • The algorithm for the Severity Index was discussed and the subcommittee will report back at the next meeting
  • Cardinal Health presented and the Council approved a general response to them giving permission for them to use the taxonomy in accordance with the copyright statement along with the language that was prepared.
  • Heard from two speakers on comparative metrics to help the Council later on with the national comparison discussions.

The work to be done by the Council at the next meeting and possibly prior to the next meeting includes:

  • Verbal order and automation positions
  • Incorporation
  • Revision of the medication error definition (may want to look at Bates definition) and possibly determining other pertinent definitions
  • State Board disciplinary actions which were not covered at this meeting
  • National comparisons

Diane Cousins offered a suggestion for changing the format of the 11/2 day meeting schedule. The Council determined that the meeting should start at noon on the first day. The motion was made and seconded to adjourn the meeting. This motion carried and the meeting adjourned at 3:05 PM.

Meeting Date