Medication Safety: One Organization’s Approach to the Challenge

The Institute of Medicine report To Err Is Human has led to increased recognition of the problem of safety in the U.S. health system [1]. Subsequent studies have continued to document the need for improvement [2]. The next step in the process of improving safety in health care is to move from theoretical recognition of problems to implementation of practical initiatives that decrease adverse clinical outcomes. Medication error is 1 facet of the clinical safety problem in the U.S. health system. A study cited in the executive summary of To Err estimated that up to 7000 deaths are caused each year by medication errors [3]. However, studies have shown that most errors do not pose a significant threat to patient safety [4–6]. In 1997, Luther Midelfort, a community hospital located in Wisconsin, sought to improve clinical safety by implementing a series of initiatives that focused on adverse drug events (ADEs). An ADE is defined as an injury resulting from medical intervention related to a drug [4]. ADEs have been shown to be a better measure of clinical safety than medication errors because by definition ADEs are linked to clinical outcomes [7–9]. The following report discusses the rationale for differentiating ADEs from the broader spectrum of medication errors and describes a practical, resource-friendly approach to enhancing patient safety.