1. Wilder, Gloria Lee PharmD


Enhancing medication safety continues to be a critical focus area in healthcare. Barriers to improving safety include a culture of blaming individuals, underreporting of errors, and neglecting to analyze and improve systems. This article describes why medication safety should be linked with a non-punitive reporting system. Drug safety issues specific to home infusion care are identified, with practical recommendations for enhancing safety and reducing medication errors. Included in this discussion is the sentinel event alert for infusion equipment free flow and the JCAHO Patient Safety Goals for 2003.


Medication safety is a top priority issue in healthcare. This article is intended to educate clinicians about medication safety in home infusion care. The "old" culture for handling medication safety issues and its flaws, new concepts of medication safety and high-risk functions in home infusion, and practical methods for preventing medication errors will be discussed.


In 1999, the Institute of Medicine (IOM), an independent advisory group to the federal government, published To Err is Human: Building a Safer Health System.1 Its findings were a shock to America: at least 44,000 to 98,000 people die in US hospitals each year as a result of medical errors. This meant that preventable medical adverse events were a leading cause of death in the United States, as a person was more likely to die from a medical adverse event than a motor vehicle accident, breast cancer, or AIDS. The IOM report described why errors occurred, identifying the true underlying cause as bad or poorly designed systems that needed to be redesigned. Making safety a national priority was the conclusion of the report.