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The American Society of Health-System Pharmacists (ASHP) and the Institute for Safe Medication Practices (ISMP) announced the creation of the National Alert Network for Serious Medication Errors (NAN) at their Midyear Clinical Meeting on December 7, 2009. Actor Dennis Quaid was among those at the meeting in Las Vegas who spoke in support of the measure, which was created as a result of the society’s IV Safety Summit in 2008.
In an effort to prevent potentially life-threatening medication errors, NAN will provide event-specific information when a serious medication error occurs. ISMP and ASHP will work together to prepare an e-mail alert describing an incident and providing suggestions on preventing it. ASHP will then forward the alert to its network of 35,000 health system pharmacists, physicians, and nurses. The goal is to provide immediate, practical ways for health system professionals to prevent an error in their own hospitals.
Information used in NAN’s e-mail alerts may be self-reported or obtained from public sources, such as news reports. When public sources are not used, the anonymity of the patient, hospital, and health care providers involved in the incident will be protected.
Dennis Quaid expressed his support for efforts that help reduce the repeat of medication errors. Addressing attendees of ASHP’s Midyear Clinical Meeting, Quaid recalled that in 2007, his newborn twins received a dose of the anticoagulant heparin that was 1000 times the normal dose. In 2006, 2 babies died from the same medication error in a neonatal intensive care unit in Indiana.
Mike Cohen, chief executive officer of ISMP, noted that although health care professionals are often inundated with e-mail alerts, alerts from NAN will require prompt attention. “The point is for the alerts to receive immediate, urgent attention from all health care providers. Our goal—to see less than 6 alerts per year.” If used correctly, NAN has the potential to prevent the recurrence of devastating, even deadly, errors.
Alerts generated for NAN will be archived and available to the public on the ASHP Web site at www.ashp.org/iv-summit.
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