Increased Communication Needed To Reduce Hospital Errors

The Joint Commission on Accreditation of Healthcare Organizations sent an alert to hospitals urging them to pay closer attention to the "medication reconciliation" process when patients are transferred between units or discharged, the AP/Seattle Post-Intelligencer reports. The commission alerted its 15,000 accredited hospitals and health organizations to avoid errors by accurately listing medications doses in "highly visible" places on patient charts and notifying staff of the information during transfers, as well as assuring that patients have accurate lists of medications and home instructions after being discharged.

JCAHO said that more than 2,000 medication reconciliation errors were received last year by U.S. Pharmacopeia, an independent group that maintains a voluntary error reporting program. JCAHO said data shows that 63% of reported medication errors resulting in death or injury were caused by lapses in communication.

Although most drug errors do not cause serious harm, estimates show that such errors kill more than 7,000 hospitalized patients nationwide each year, the AP/Post-Intelligencer reports. JCAHO in a press release said that "[a]pproximately half" of errors resulting from lack of communication "would have been avoided through effective medication reconciliation" (Tanner, AP/Seattle Post-Intelligencer, 1/25).