A number of barriers to the enhancement of patient safety through a reduction of medication errors have been identified. These include a blame culture; lack of leadership; lack of peer-review protection; and the absence of a collaborative voluntary national reporting system. The latter would provide oversight and help healthcare providers avoid recurrence of these adverse drug events stemming from human error.

A voluntary practitioner's reporting system similar to that promoted by the Institute for Safe Medication Practices Canada (ISMP Canada) has been shown to be successful in the United States in achieving the goal of enhancing patient safety. ISMP Canada needs collaboration with other reporting systems to gain more insight and knowledge of the causal factors underlying medication errors. This collaborative mode fits into the conceptual model of the medication incident reporting and prevention program currently being developed by a coalition of key stakeholders including Health Canada, ISMP Canada and the other health care professional organizations.

The model for a successful patient safety enhancement strategy as proposed by Baker and Norton in their lead paper is a valid one. In the meantime, there is enough knowledge and information about medication errors to permit our putting prevention strategies into practice.


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