Benchmarking Medication Error Rates
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for benchmarking. Yet, we must question the wisdom of applying the benchmarking concept to the medication use process when the focus is on error rates. The true incidence of medication national benchmark for medication errors errors varies, depending heavily on the rigor with which the events are identified
Medication Error Rates In Hospitals
and reported.. Certainly, the confusion surrounding the term "benchmarking"perpetuates the myth that one can gauge the quality and safety of
Medication Error Rates In Nursing Homes
the medication use process simply by comparing error rates, both within an organization and externally. Benchmarking is an ongoing process that determines how other organizations have achieved the best performance and suggests
Medication Error Rate Calculation
ways for adapting the best practices that result in this exceptional performance. Although measurement is one of its components, effective benchmarking is a dual process that requires two products: benchmarks and enablers.1 Benchmarks are measures of comparative performance that answer the question: "What is your level of performance?" Alone, this information has little use in improving performance. Benchmarking must also provide a systematic method of understanding medication error statistics the underlying processes that determine organizational performance. To that end, enablers must be identified. Enablers are the specific practices that lead to exemplary performance and answer the question: "How do you do it?" Overlooking either one of these components in the benchmarking process renders it useless, even dangerous! Currently, there is no consistent process among healthcare organizations for detecting and reporting errors. Since many medication errors cause no harm to patients, they remain undetected or unreported. Still, organizations frequently depend on spontaneous voluntary error reports alone to determine a medication error rate. The inherent variability of determining an error rate in this way invalidates the measurement, or benchmark. A high error rate may suggest either unsafe medication practices or an organizational culture that promotes error reporting. Conversely, a low error rate may suggest either successful error prevention strategies or a punitive culture that inhibits error reporting. Also, the definition of a medication error may not be consistent among organizations or even between individual practitioners in the same organization. Thus, spontaneous error reporting is a poor method of gathering "benchmarks;"it is not designed to measure medication error rates. Of equal concern is the mistaken belief that benchmark
Know Governance Job Openings Login to PA-PSRS About PA-PSRS Data Interface Facility Reporting Information Login to PassKey About national average medication error rate PassKey Advisory Library Patient and Consumer Tips Press Releases Healthcare-Associated benchmark data for medication errors Infections Brochures Related Organization Links The Authority in the News Driving Change Patient Safety medication error statistics 2015 Tools Calendar Public Meetings ADDRESS: Patient Safety Authority 333 Market Street Lobby Level Harrisburg, PA 17120 Phone: 717-346-0469 Fax: 717-346-1090 SearchAdvanced Search Understanding http://www.ismp.org/newsletters/acutecare/articles/19980909.asp the Benchmarking Process PA PSRS Patient Saf Advis 2004 Dec;1(4):19. _______________This article is excerpted from the book Medication Errors by Michael Cohen, RPh, MS, ScD. Dr. Cohen is President of the Institute for Safe Medication Practices (ISMP) and serves as an expert advisor to PA-PSRS in the http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2004/dec1(4)/Pages/19.aspx area of medication safety._______________Benchmarking is an ongoing process that determines how other organizations have achieved optimal performance. Through the process of benchmarking, ways are suggested for adapting the best practices that result in exception performance. Although measurement is one of its components, effective benchmarking is a dual process that requires two products: performance measurement and enablers.Benchmarks are measures of comparative performance that answer the question: What is your level of performance? By itself, this information has little use in improving performance. To be effective, benchmarking must also provide a systematic method of understanding the underlying process that determines an organization’s performance. To that end, enablers must be identified. Enablers are the specific practices that lead to exemplary performance; they answer the question: How do you do it? Overlooking either one of these components in the benchmarking process renders it useless, even dangerous.Although m
in our healthcare community are due to medication errors. As in the U.S., Australia and the United Kingdom, medication errors have imposed a serious threat to patient safety, https://www.ismp-canada.org/smp0103.htm and have become a major public health issue in Canada. As institutions and healthcare providers are paying increased attention to this concern, one of the frequently asked questions and sought answer is: "What is our medication error rate, and how does it compared with others?" The benchmarking question is often raised because many continue to believe that "error rate" is a measure of patient safety. The reality medication error is, that the medication error rate determination is derived from most, if not all, reported incidents. Kenneth Barker's study on error rates, presented at the American Society of Hospital Pharmacists’ Clinical Meeting in Las Vegas, December 2000, showed that medication error rates captured by incident reports is the least effective and least reliable determinant of the true error rate. 1 The number of medication errors will medication error rate vary, depending very much on the vigor with which errors are identified and reported. Although most hospitals have a relatively standardized method for defining a medication incident (a medication error that reaches a patient), the manner in which they are detected, and reported, differ vastly. Simply counting "numbers" and comparing statistics of medication errors lacks validity, and more importantly can dangerously undermine efforts towards full reporting and learning. A "high error rate" when comparing numbers within an organization or externally, can mean there are unsafe medication practices, or it could reflect an organizational culture which promotes error reporting and learning. Conversely, a ‘low error rate’ might suggest a successful error prevention program, or may be the result of an inherent punitive approach which in turn, inhibits individuals from reporting errors and analyzing causes of errors. Hospitals which focus their attention on maintaining a "low error rate", will inadvertently promote an unproductive cycle of underreporting of errors and will therefore, allow unrecognized weaknesses in the medication use system to continue. Low error rates often result in false sense of security and an implicit acceptance of preventable errors. A hospital's strategy needs to place less emphasis on comparing error r
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