INSMP Centres Presentations
ES proposal for buiding http://www.intmedsafe.net   

A variety of medication error reporting systems have been established at a national level. In different countries, medication errors may be reported to specific reporting programs or to broader patient safety reporting programs.
These systems cooperate into the International Network of Safe Medication Practice Centres, contributing by this way to a better dissemination of recommendations for improving the patient safety and preventing medication errors.

Institute for Safe Medication Practices (ISMP)
http://www.ismp.org/

The medication error reporting program of the Institute for Safe Medication Practices (ISMP) collects reports from healthcare practitioners since 1975. In 1991, ISMP merged its MERP with the US Pharmacopeia. In 1992, the Food and Drug Administration (FDA) began monitoring these medication error reports. Healthcare practitioners and consumers can submit reports and associated material in confidence. The information, after removal of name and contact information, is anonymously forwarded to the Food and Drug Administration (FDA) and to the manufacturer to inform them about pharmaceutical labelling, packaging and nomenclature issues that may foster errors by their design. ISMP analyzes the medication error reports and addresses recommendations to healthcare practitioners, community pharmacists, nurses, consumers, pharmaceutical companies and authorities.

Since the beginning of the ISMP MERP, feedback information has been provided in the columns of “Hospital pharmacy”. The feedback information is also available in many others healthcare journals, on ISMP Website and with several dedicated newsletters, formerly “ISMP Medication Safety Alerts!”, are published monthly or biweekly with a specific format for their audience: Acute Care Edition, Community/Ambulatory Care Edition, Consumer Edition, Nursing Edition. Tools for improvement of medication safety practices, such as IMSP Medication Safety Self Assessment°, educational services, and others consulting services are also provided.

Institute for Safe Medication Practices Canada (ISMP-Canada)
http://www.ismp-canada.org/

Since 2000, ISMP-Canada receives information on medication errors from individual healthcare practitioners and institutions on a voluntarily basis. In addition, hospitals may report anonymous information on medication errors through ISMP-Canada’s “Analyze-ERR”, a software documentation tool designed to track and analyse medication errors. Feedback information is provided in “ISMP Canada Safety Bulletin”, available on ISMP-Canada website and through several journals, such as the “Canadian Journal of Hospital Pharmacy”, “Canadian Association of Critical Care Nurses Dynamics”, “Hospital News”.

ISMP-Canada participates in cooperative programs with professional organizations and university in Canada not only by the way of educational programs about medication errors and their prevention. A coalition of stakeholders including the Canadian Society of Hospital Pharmacists (CSHP), Health Canada’s Marketed Health Products Directorate, the Canadian Institute for Health Information (CIHI) and further the Canadian Association of Chain Drug Store, the Canadian Healthcare Association, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Pharmacists Association, the Canadian’s Research Based Pharmaceutical Companies, the College of Family Physicians of Canada, the Consumer Association of Canada and the Royal College of Physicians and Surgeons of Canada, formerly the Canadian Coalition on Medication Incident Reporting and Prevention (CCMIRP) led to the creation in 2004 of a national Canadian MERS (CCMIRP 2002). Operated by ISMP-Canada, it is closely aligned with the work and the objectives of the Canadian Patient Safety Institute (CPSI).

Instituto par el Uso Seguro de los Medicamentos (ISMP-Spain)
http://www.usal.es/ismp

Since its founding in October 1999, ISMP-Spain has maintained a national medication error reporting program. This program is voluntary, confidential and independent. It collects observations and experiences concerning those potential or actual medication errors that healthcare professionals voluntarily report. The information is independently analyzed, with no conflicts of interest neither administrative pressure, and all information is treated confidentially. Healthcare professionals can either complete a report form or contact the ISMP-Spain either by e-mail, fax or telephone to report medication errors with complete confidentiality.

ISMP-Spain carefully reviews and analyzes all reported errors, and depending on the characteristics sends a copy of the report to the Spanish Medicine Agency (AEM) and to the pharmaceutical companies whose products are mentioned in the reports. The information is also shared with the ISMP-USA.

Feedback information is provided by ISMP-Spain on its website and in Spanish healthcare journals.

NHS National Patient Safety Agency (NPSA)
http://www.npsa.nhs.uk

The National Patient Safety Agency is a Special Health Authority created in July 2001 to co-ordinate reporting, analyzing and learning from “adverse incidents” and “near misses” involving NHS patients.

After testing in 2003, the National Reporting and Learning System (NRLS), has been launched in 2004 to collect information on “patient safety incidents”, including medication errors reports, from all 607 NHS organizations in England and Wales. The NRLS is the only national reporting system covering all healthcare settings, i.e. primary care, acute care, learning disabilities, mental health and ambulance care. Designed to complement local reporting systems, the information is stored anonymously by the NRLS. All reports related to patient safety are entered into the organization’s own risk management system and then sent automatically direct to the NPSA, where the information relating to individuals (staff or patients) is removed. An electronic web-based reporting form is also available. Patients and careers can report by telephoning to a free phone number to speak with a member of the Patient Advice and Liaison Service (PALS) team.

The information provided by the NRLS is a key component of the Patient Safety Observatory (PSO) and assists in the identification and understanding of error, and the development of solutions. In 2005, according to the first report of the NRLS and the PSA, medication errors represented 20.8% of patient safety incidents reported in general practice, 8.6% in acute hospitals, 3.4% in mental health trusts, 5.7% in learning disabilities services, 8.8% in ambulance services (NPSA, 2005).

The NPSA uses three distinct formats for communicating patient safety information to the NHS. The formats are : “Patient safety alert” requiring prompt action to address high risk safety problems ; ”Safer practice notice”, which strongly advises implementing recommendations or solutions; and “Patient safety information” which suggests issues or effective techniques that healthcare staff can consider to enhance safety.

The NPSA produces also number of publications, videos and tools, including e-learning, to assist the NHS. In partnership with the NPSA, BMJ Publishing Group, the Institute for Healthcare Improvement (IHI) “saferhealthcare” (www.saferhealthcare.org.uk) is a website being both a patient safety information resource and a communication channel for sharing experiences.

Prescrire’ Programme Preventing the Preventable
(in French: Programe Prescrire Éviter l’Évitable)

The Réseau REEM (Réseau Épidémiologique de l'Erreur Médicamenteuse, meaning French Epidemiologic network for medication errors reporting) is the first French medication errors reporting system proposed by AAQTE, a non-profit organization promoting the quality assurance of drug therapy and evaluation in 1998.

http://www.adiph.org/aaqte/index.html (in French only)
Since 1999, the Réseau REEM receives medication errors reports from individual healthcare practitioners at a national level. This program is voluntary, confidential and independent. Healthcare professionals can either complete a report form or contact the Réseau REEM either by e-mail, fax or telephone to report medication errors with complete confidentiality. Feedback information is provided in French healthcare journals like the “revue Prescrire” or “Le pharmacien hospitalier”.

The small-sized AAQTE is currently merging its medication error reporting program within the "Association Mieux Prescrire" (AMP), the “revue Prescrire” and “Prescrire International” Editor, widening the voluntary reporting program to more healthcare practitioners, in particular doctors and nurses, from hospital setting to ambulatory care, and expanding the reporting system from medication errors to overall patient safety. The name of the reporting system remains the same, REEM meaning “Réseau pour Éviter l’Évitable en Médecine” (Preventing the preventable in medicine).

In December 2005, a special issue of the revue Prescrire was dedicated to learning from medical errors:
http://www.prescrire.org/cahiers/dossierEviterAccueil.php (in French only),
with a special focus on medication errors:
http://www.prescrire.org/cahiers/dossierEviterPart34.php (in French only).
During 2007, a special part of the Prescrire’ website will open a new designed medication and medical errors learning and reporting program:
http://www.prescrire.org/eviterEvitable/index.php

The following table summarizes the main characteristics of the actual members of the International Network of Safe Medication Practice Centres

Summary of the characteristics of INSMPC Members