NCC MERP Taxonomy of Medication Errors

1 1 NCC MERP Taxonomy of Medication Errors1 PreambleThis document provides a standard Taxonomy of Medication Errors to be used incombination with systems analysis in recording and tracking of Medication Errors . It isnot intended to assess blame. The document is not all-inclusive, but can be expandedas new issues arise. The purpose of this Taxonomy is to provide a standard languageand structure of Medication error-related data for use in developing databasesanalyzing Medication error is provided to assist in the application of this instrument. Please note that thetaxonomy is not designed as a reporting form, but is rather a tool to categorize andanalyze reports of Medication is recommended that health care organizations develop systems and procedures tocollect adequate information needed to analyze and report Medication Errors at the timethe error occurs.

2 In most cases, it should not be necessary to conduct retrospectiveaudits to collect the needed information in order to apply this effectiveness of the Taxonomy , and the resulting analysis of Medication errorreports, is dependent upon the amount and the quality of the data collected throughmedication error reports. For optimum application of the Taxonomy , include as muchinformation as possible in the instrument. However, if all the information described inthe Taxonomy is not collected, the information that is available should be categorized asshown in the that some fields require selection from a defined list of choices and otherfields require entry of free use the Taxonomy properly, choose the most specific code available.

3 If thislevel of specificity is not possible, select the code of the parent INFORMATION 1 Copyright 1998 by National Coordinating Council for Medication Error Reporting andPrevention (NCC MERP). All rights reserved. The NCC MERP Taxonomy of Medication Errors text maybe reproduced without special permission by individual health care facilities for internal non-commercialuse only. For any other purpose, express permission of the NCC MERP is required. For permission,contact the Office of the Secretariat, United States [ The purpose of this section is to:*permit entry of an identification code that allows matchinginformation in the Taxonomy with Medication error reports*allow sorting and reporting of Medication error reports ( ,analyze Medication error reports by age ranges)For a report of Category A error (see item #31), this section can be omitted.]

4 Otherwise, complete as many of these sections as possible]. Identification Number or Age - Date of Weight [may be omitted unless directly pertinent to the error ( , Medication overdose in a pediatric patient)].20 THE EVENT21 DATE (mmddyyyy)[Complete as many items as possible in this section] Date of Date of Initial Date of Follow-up Time of Error (24 hour clock)23 SETTING (of initial error)[Select either one category or one subcategory, whichever provides thebest known information] Adult Day Health Living/Board and Rescue Health Food Step Care Unit (ICU) ICU/Step Down (InfantTransitional) Term Acute Procedures Room (PACU) Health Health Nursing Facility (Free Standing) Outpatient Care Patient's Health Long Term Care Prescriber's Unknown24 SETTING (Where Error Perpetuated)

5 [Select as many settings as are applicable] Adult Day Health Living/Board and Rescue Food Step Care Unit (ICU) ICU/Step Down (InfantTransitional) Term Acute Procedures Room (PACU) Health Health Nursing Facility (Free Standing) Outpatient Care Patient's Health Term Care Care Prescriber's Unknown25 DESCRIPTION OF EVENT[This is a free text entry field. The user should provide a narrativedescription of the event, including how the error was perpetuated anddiscovered. Other relevant information should be included, such as: Laboratory data or tests, including dates Other relevant history, including preexisting medical conditions( , allergies) Concomitant therapy Dates of therapy Indication for use (Diagnosis) Medical intervention(s) following the error Actions taken and recommendation for prevention].

6 630 PATIENT OUTCOME[NCC MERP recommends that Medication error information be collected andreported as soon as possible, while the information is still fresh. It is recognizedthat the eventual patient outcome may change from the time when themedication error initially occurs. For example, the patient may initially requirehospitalization due to the error, but eventually die as a result of the error afterseveral weeks of treatment and support in the hospital. If the patient outcome orother variables should change, the Medication error information can be updatedor corrected at a later selecting the patient outcome category, select the highest level severity thatapplies during the course of the event. For example, if a patient suffers a severeanaphylactic reaction (Category H) and requires treatment (Category F) buteventually recovers completely, the event should be coded as Category H ( ).]

7 Select only one of the Medication error categories or subcategories, whicheverbest fits the error that is being Category A Circumstances or events that have the capacity to cause error32 ERROR, NO HARM[Note: Harm is defined as temporary or permanent impairment of thephysical, emotional, or psychological function or structure of the bodyand/or pain resulting therefrom requiring intervention.] Category BAn error occurred but the error did not reach the patient(An error of omission does reach the patient.) Category C An error occurred that reached the patient, but did not cause patient Medication reaches the patient and is Medication reaches the patient but not Category DAn error occurred that reached the patient and required monitoringto confirm that it resulted in no harm to the patient and/or requiredintervention to preclude harm733 ERROR.

8 Category EAn error occurred that may have contributed to or resulted intemporary harm to the patient and required Category FAn error occurred that may have contributed to or resulted intemporary harm to the patient and required initial or Category GAn error occurred that may have contributed to or resulted inpermanent patient Category HAn error occurred that required intervention necessary to sustainlife34 ERROR, Category IAn error occurred that may have contributed to or resulted in thepatient s INFORMATION - #1 [PRODUCT THAT WAS ACTUALLY (ORPOTENTIALLY) GIVEN][ Classify each Medication involved in a Medication error. Include the intendedproduct for use, as well as the actual product used, if these are different.]

9 Selectnumbers 51-54 to code the product actually or potentially administered. Selectnumbers 55-59 to code the intended product, if different from the product actuallyadministered or intended].51 GENERAL[Select and complete as many items as possible in this section]. of Drug (or other products, if applicable) Proprietary (Trade) Established (Generic) Compounded , Frequency & of of Labeler or Distributor952 DOSAGE FORM[ Note: This list is not all inclusive; other dosage forms not listed should becaptured under "other". Select one item from this section] (spray and metered) - CONTAINER[Note that these are some examples of packaging frequently involved inerrors. The list does not include all packaging configurations available in themarket place.

10 Select one item from this section] Dose Vials (Injectable) Dose Vials/Ampuls (Injectable) Solutions (small and large volume parenterals) (Please specify)54 PHARMACOLOGIC - THERAPEUTIC CLASSIFICATIONThe council recommends the use of the pharmacologic-therapeuticclassification system defined by either the American Society of Health-Systems Pharmacists ( , AHFS code) or the Veterans Administration ( ,VA codes).1055 PRODUCT INFORMATION - #2 (PRODUCT THAT WAS INTENDED TO BE GIVEN)56 GENERAL[Select and complete as many items as possible in this section]. Proprietary (Trade) Established (Generic) Compounded , Frequency & of of Labeler or Distributor57 DOSAGE FORM[ Note: This list is not all inclusive; other dosage forms not listed should becaptured under "other".