In the 1999 research studies began to review the problem of medical errors and how they occurred. Studies and reports, such as the Institute of Medicine IOM report in 1999, strongly suggest that most medical errors are related to systems and processes and not individual negligence or misconduct. The IOM report recommended that the key to addressing medical errors is to focus on improving the processes used to deliver healthcare and not placing blame on the individuals involved.
Approximately 1.3 million people are injured annually in the United States following "medication errors". The FDA defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or harm to a patient”.
The U.S. Food and Drug Administration (FDA) currently review medication error reports that come from drug manufacturers and through Med Watch, the agency's safety information and adverse event reporting program. The agency also receives reports about medication errors from the Institute for Safe Medication Practices (ISMP) and the U.S. Pharmacopeia.
Some things the FDA has put into place to prevent medication errors: * Drug Name Review:
To minimize drug name confusion, FDA reviews about 400 drug names a year that companies submit as proposed brand names. The agency rejects about one-third of the names that drug companies propose. * Drug Labels:
FDA regulations require all over-the-counter (OTC) drug products (more than 100,000) to have a standardized "drug facts label." FDA has also improved prescription drug package inserts for health care professionals. * Drug Labeling and Packaging:
FDA works with drug companies to reduce the risk of errors that may result from similar-looking labeling and packaging, or from poor product design. * Bar Code Label Rule:
In accordance with an FDA rule that went into effect in 2004, bar codes are required on product labels for certain drugs and biologics such as blood. When used with bar code scanner and computerized patient information systems, bar code technology can help ensure that the right dose of the right drug is given to the right patient at the right time. * Error Analyses:
FDA reviews about 1,400 reports of medication errors per month and analyzes them to determine the cause and type of error. * Guidance’s for Industry:
FDA is working on three new guidance’s—one on complete submission requirements for analysis of trade names, one about the pitfalls of drug labeling, and another on best test practices for naming drugs. * Public Education:
FDA spreads the message about medication error prevention through public health advisories, medication guides, and outreach partnerships with other organizations.

Types of technology that are being used in reducing medication errors in healthcare organizations

EMR- Electronic Medical Record

Computerized physician order entry

Computerized identifiers such as bar coding of patient wrist bands, lab tests, and medications

Computerized pumps

Automated dispensing cabinets/drug dispensing robots

Medication errors occur for a variety of reasons. For example, miscommunication of drug orders can involve poor handwriting, confusion between drugs with similar names, poor packaging design, and confusion of metric or other dosing units.
Medication errors have been found to be one of the most common causes of medical death, costing the lives of over 7,000 patients each year (Meadows 2003). Many more suffer permanent disability because of medication errors. Yet medication errors are considered the most preventable of all medical errors.
In response to public and professional concerns about medical errors, the Joint Commission of
Accreditation of Healthcare Organizations (JCAHO) revised and added new standards with an emphasis on patient safety. These standards went into effect in July 2001. They address fostering an environment in which patient safety is key and medical errors are analyzed and evaluated for ways to prevent them from recurring. Many organizations, including the National Patient Safety Foundation, the Leapfrog Group, and the Institute for Healthcare Improvement, were formed with the goal of reducing medical error and improving patient safety. Improving the safety of using medication is the third goal by the Joint Commission.

Medication errors are a serious threat to patient safety in both hospitals and in the community. Risk managers are taking a more proactive approach to preventing medication incidents in hospitals.

Something’s risk managers do in preventing medication errors in a healthcare organization: * Facilitate the creation of an open and non-punitive culture in the organization to encourage error reporting, to ensure learning from error occurs, and ensure improvement needs are identified. * Encourage reporting of "near-misses" to identify areas for improvement before an incident actually occurs. * Coordinate educational sessions for staff to discuss errors and their prevention strategies. * Focus efforts on specific high alert drugs and error-prone situations. References are available which identify these areas. * Perform an objective self-assessment of the hospital's risk for medication errors. * Involved in the review and "root-cause" analysis of medication errors. * Participate and provide input into the development of quality improvement initiatives. * Share error reduction and prevention strategies and other patient safety information with others
One of the recommendations to reduce medication errors and harm is to use the “five rights”: the right patient, the right drug, the right dose, the right route, and the right time. The five rights focus on individual performance and not on human factors and system defects that may make completing the tasks difficult or impossible. These five rights were introduced to improve patient safety in an organization.