• In 1999, the Institute of Medicine published To Err Is Human: Building a Safer Health System, in which they stated that between 44,000 and 98,000 people die in hospitals each year as a result of preventable medication errors, and laid out a strategy for reducing these errors.
• Founded in 1995, the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is an independent body composed of 27 national organizations whose mission is to address interdisciplinary causes of medication errors and promote the safe use of medications.
• NCC MERP defines a medication error as a preventable event that may cause or lead to inappropriate mediation use or patient harm while the medication is in the control of the health care professional, patient, or consumer.
• NCC MERP promotes the safe use of medications and increased awareness of medication errors through increased reporting and promotion of medication error prevention strategies. While NCC MERP states that there is no acceptable rate for the incidence of medication errors, due to differences in organizational culture, patient populations, and types of reporting and detection systems, NCC MERP does not recommend the use of medication error rates to compare health care organizations. There are no national- or state-level benchmarks for health care medication error rates.
• NMDOH operates six health care facilities, each of which serves a distinct population. Beginning in FY19, each facility will monitor and report the rate of significant medications errors, defined as category D or higher, according to the NCC MERP Index for Categorizing Medication Errors. A category D medication error is an error that reached the patient and required verification that the patient was not harmed or actions were taken to prevent harm to the patient.  The FY19 Quarter 1 results are as follows:
  • Quarter 1:  .4

The target of < / = 2.0 was met for Quarter 1.  Strategies and actions in place will continue in an effort to reduce the number of significant medication errors.

• Health care professionals
• Patients
• Consumers

• Encourage medication error reporting within a non-punitive, continuous quality improvement framework.
• Establish an organizational culture to help minimize provider behaviors associated with higher medication errors.
• Establish a goal to continually improve systems to prevent harm to patients due to medication errors. Monitor actual and potential medication errors that occur, and investigate the root cause of errors with the goal of identifying ways to improve the medication use system to prevent future errors and potential patient harm. Apply lessons learned to improve the system.

• Foster a culture that minimizes at-risk provider behavior and supports medication error reporting within a non-punitive, continuous quality improvement framework.
• Review and ensure consistent, reliable, and system adoption of best practices to prevent medication errors.
• Establish facility-specific and/or patient-population specific goals to continually improve systems to prevent harm to patients due to medication errors. Monitor actual and potential medication errors that occur and investigate the root cause of errors with the goal of identifying ways to improve the medication use system to prevent future errors and potential patient harm. Apply lessons learned to improve the system.

Q1: Establish a facility-specific and/or patent-population specific baseline medication error rate and articulate an FY19 performance target for the facility and/or patient population. Completed.

Q2: Develop and adopt a written Medication Error Reduction Plan for each facility, which includes monitoring actual and potential medications errors that occur, investigating the root cause of errors, and identifying opportunities for systemic or process changes to reduce the errors.

Q3: Establish a forum and process for all facilities to jointly review and learn from external medication-related error reports and/or alerts.

Q4: Conduct facility-specific and/or patient-population specific review to assess the effectiveness of the Medication Error Reduction Plan; revise and re-adopt the Plan as appropriate.