Risk management from a collaborative perspective

Medication error studies, which reveal mistakes that occur, are different from claims analyses, which show the medication errors that cause harm. Warfarin and other high-risk and narrow therapeutic index agents are more frequently involved in claims because errors, whether frequent or not, are more likely to result in harm. Pharmacists in collaborative relationships with physicians can reduce medication errors by identifying potential risks, selecting and implementing techniques for addressing possible errors, monitoring the system, and making changes as necessary using continuous quality improvement principles. Five recommended approaches for preventing medication errors include listening, learning, and thinking; monitoring, checking, and reevaluating; documenting, charting, and reading; talking, smiling, and communicating; and implementing a system of quality management.