This is the first of a new column on safe medication practices to be published in Hospital News by the Institute for Safe Medication Practices Canada (ISMP Canada). ISMP Canada is an independent, nonprofit organization established to collect and analyze medication error reports and to develop strategies and recommendations for enhancing patient safety. ISMP Canada intends to serve as a national resource for promoting safe medication practices throughout the Canadian healthcare community.

The purpose of this column is to share information on medication issues that affect patient safety. Useful information is gathered from the healthcare community through medication error reports. These reports will include "near-misses" that have potential to cause harm to patients. ISMP Canada then shares with the healthcare community recommendations for safe medication practices so that similar errors are prevented in other institutions. Practitioners are encouraged to send reports to ISMP Canada by mail, fax or online with our web site: www.ismp-canada.org. Reporters are assured that all information is treated with strict confidence.

What is a medication error? How is a medication error different from an adverse drug reaction? This is an important question that should be addressed when we ask practitioners to report medication errors. Adverse drug events stem from two different sources: adverse drug reactions (ADRs) and medication errors. An ADR is a non-preventable event that is caused by the inherent drug properties. Adverse drug reactions are side effects of a drug that occur in the course of error-free medication use. In contrast, medication errors are PREVENTABLE events that occur in the process of medication use: prescribing, dispensing and administration of medications. They are usually caused by human errors that are manifested in drug distribution, drug names, labeling, computer program design and drug delivery design. Although both ADR and medication errors can harm patients, the process of identification, evaluation and strategies planned to reduce the probability of such harm are different.

Do we need a culture change? Definitely, we need a non-punitive and open environment in an institution to report and address medication incidents and other related issues for the purpose of making a real improvement in patient safety. This philosophy should come right from the top management down to all practitioners including physicians, nurses, pharmacists, and risk managers. It is too easy to blame a practitioner who triggers the event. Punishing the practitioner will not prevent the same error from occurring again in a similar situation. All error experts agree that medication errors due to human error are difficult to eliminate. However, investigating and analyzing the root causes of an error will usually reveal system flaws and the related processes that have allowed the event to happen. By increasing "safety nets" in systems we can attempt to decrease the likelihood of similar errors. It is only in non-punitive cultures that practitioners will be willing to report medication errors and near misses for the purposes of investigation and preventing recurrences.

It is also important to distinguish between staff incompetence and human error. Watch for a special topic on Human Error, which will appear in the next issue. John Senders, an expert in this field, will be happy to share his knowledge and experience with the readers.

A Safe Medication Practice Committee is being established in a number of hospitals in the Greater Toronto Area. These committees, or working groups, are under the auspices of either the P&T Committee or the Hospital's Quality and Risk Management Committee. Examples of hospitals include University Health Network, Sunnybrook and Women's College Health Science Centre, The Scarborough Hospital, William Osler Health Care Corporation and the Centre for Addiction and Mental Health. The mandate and terms of references focus on prevention, and development of strategies to reduce medication errors. Although all health care professionals have a role to play and contribute to these important committees, pharmacists have taken the lead in their establishment of ISMP Canada. This organization is committed to provide support to the patient safety initiative and will facilitate linkages and communication among these groups and others who are planning for a similar venue. Hospitals that have established similar committees are encouraged to contact David U at davidu@ismp-canada.org to share strategies and related information.