Network Launched to Prevent Medication Errors

<"">Medication errors kill one person per day in the U.S., and injure about 1.3 million every year, according to the U.S. Food & Drug Administration. That sad toll recently prompted two leading medical organizations to implement a new national alert system aimed at helping to prevent dangerous and repeated medication errors.

According to their press release, the American Society of Health-System Pharmacists (ASHP) and the Institute for Safe Medication Practices (ISMP) are partnering to develop the National Alert Network for Serious Medication Errors. The network will be triggered when a seriously harmful or potentially seriously harmful error has occurred. The alert will include a description of the error, as well as recommendations to prevent the same error in the future.

The idea of the National Alert Network for Serious Medication Errors stemmed from ASHP’s 2008 I.V. Safety Summit, which focused on ways to end medication errors, such as the one that seriously harmed actor Dennis Quaid’s twins. In November 2007, the then 2-week-old infants, being treated for a staph infection, were given 10,000 units of heparin instead of the 10-unit dose for babies. The network was formally launched in December.

According to the press release, ASHP will disseminate the email alerts to its extensive network of nearly 35,000 health-system pharmacists, as well as other engaged health care practitioners, including physicians and nurses. When an alert is sent out, recipients can use the recommendations provided to take immediate action to make sure the error is not repeated at their facility. With broad reach this system can help prevent a similar error from occurring again anywhere in the country.

The event-specific information contained in the alerts will be obtained through a variety of channels, including voluntary reporting and news reports. When the information is not obtained through public resources, the alerts will not identify the hospital, patient or health care providers involved in the error. The alerts will be archived and available to the public on the ASHP web site at

“This rapid system of sharing information with physicians, nurses, pharmacists and others in health care sets this alert system apart from previous efforts,” Henri R. Manasse, Jr., ASHP Executive Vice President and CEO, said in the press release. “It is heartbreaking and frustrating to see the same mistakes happen again and again. This alert system is a significant and imperative step – creating more transparency and breaking the chronic cycle of medication errors.”

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