Which of the following agencies analyzes medication errors, near misses, and potentially hazardous conditions as reported by pharmacists and other practitioners?

a. ASHP
b. ACPE
c. ISMP
d. DRG

 Answer: (c). ISMP (Institute for Safe Medication Practices) is an independent nonprofit agency that analyzes medication errors, near misses, and potentially hazardous conditions as reported by pharmacists and other practitioners.

ISMP then makes appropriate contacts with companies and regulators, gathers expert opinion about prevention measures, and publishes its recommendations.

To assist pharmacists in the process of minimizing the occurrence of medication errors, many state boards of pharmacy are contemplating or already requiring community pharmacies to have a continuous quality improvement program in place.

Many of these state’s regulations include the requirement of root cause analysis (RCA) in the case of sentinel events.

The Joint Commission defines a sentinel event as an “unexpected occurrence involving death or serious physical or psychological injury or risk thereof,” and recommends completing an RCA for all sentinel events for health care organizations in which they accredit.

It is anticipated that RCA for sentinel events may be required as part of an accreditation program for community/ambulatory pharmacies.