Medication errors analysis is an opportunity to improve practice

The United States Pharmacopeia (USP) Medication Errors Reporting (MER) Program collected and cataloged 2,213 reports between October 1991 and November 1996. Medication errors occur in all health care facilities, involve health care practitioners from all disciplines, and involve drugs from all categories, including neuromuscular blocking agents (38 out of 2,213). This class of drugs is discussed as an example of the program, and we trust will serve the reader as an educational guide about medication errors that occur with drugs in any class. When used inappropriately, they represent a higher morbidity and mortality than many other drug classes analyzed. Reports indicate various causes for the errors, such as similar-appearing products, and include suggestions by practitioners to prevent recurrence of the error. The USP Advisory Panel on Medication Errors has developed recommendations for facilities that are intended to prevent errors with neuromuscular blocking agents (NMB). The USP Medication Errors Reporting Program is presented in cooperation with the Institute for Safe Medication Practices (ISMP).