1. Alexander, Mary BS, CRNI(R), CAE

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In my 2004 November/December editorial, I touched on a subject that is no doubt a concern for all of our readers-medication safety. Infusion nurses have become especially concerned with reducing medication errors because the administration of intravenous drugs can carry swift and irreversible consequences.

Figure. Mary Alexand... - Click to enlarge in new windowFigure. Mary Alexander, BS, CRN, CAE INS Chief Executive Officer Editor, Journal of Infusion Nursing

When the Institute of Medicine issued its 2000 report, To Err is Human: Building a Safer Health System, which named medication errors as the 8th leading cause of death in the United States, it sent a shockwave through the healthcare industry and touched off a series of studies regarding the human factor and process improvement in the prevention of such errors. Although nurses make up the largest group of healthcare professionals involved in medication errors, the profession still lags behind other healthcare fields in published research on medication safety. As the premier organization for infusion nurses, INS took a crucial step in advancing awareness of medication errors and the prevention thereof by cohosting the "State of the Science on Safe Medication Administration" symposium in July 2004.


INS partnered with the University of Pennsylvania School of Nursing, the Hospital of the University of Pennsylvania, and the American Journal of Nursing in the invitational symposium to identify the issues that most threaten the safety of medication administration and recommend policy changes that will reduce errors and save lives. The symposium-which was supported by a conference grant from the Agency of Healthcare Research and Quality (AHRQ 1 R13 HS14836-01) and unrestricted grants from manufacturers of pharmaceuticals and other products designed to promote safe medication administration-turned out to be a fruitful exchange of ideas, and brought to light some new approaches to enhancing safety not only through clinicians, but also through manufacturers, pharmaceuticals, and administrators.


We are pleased to supplement this issue of the Journal of Infusion Nursing with the report that resulted from the symposium. The Executive Summary, which appears on the following pages, provides an overview of the problem of medication safety, and describes the structure and goals of the State of the Science meeting. The summary also identifies some of the most common barriers to medication safety, aspects of healthcare that are, sadly, familiar to many of us, including a lack of funding for research that would improve processes, a lack of education about medication safety in nursing school curricula, poor communication among allied healthcare professionals, and a lack of nurse participation in setting policy.


The report contained in the supplement represents a new trajectory of thinking in nursing practice. The contributors to the report are some of the most progressive researchers in healthcare. Among them are Victoria L. Rich, Chief Nursing Officer at the Hospital of the University of Pennsylvania, who presents a new model for rooting out potential causes of medication errors and urges nurses to undertake research to improve patient safety; and Ronda Hughes, senior health scientist administrator and senior advisor on end-of-life care at the Agency for Healthcare Research and Quality, who questions the culture of healthcare that punishes clinicians for errors instead of learning from them. Each contributor's perspective is a critical voice in the dialogue that must continue if we are to improve the safety of medication administration.


We are proud to bring you the information in this supplement, and we urge you to share it with your colleagues, but we would not have been able to publish the report without the participation of all those who attended the meeting. I would like to personally thank Diana Mason, Editor-in-Chief of the American Journal of Nursing, for her help in disseminating this information through her journal and ours. She has long been a supporter of the infusion nursing specialty and a great partner in advancing the science and practice of nursing through published research.


As you read this issue, consider how you can become involved in improving medication safety in your organization. Most studies on medication safety have been hospital-based, so if you work in an alternate care setting, you may be able to offer new insights. I urge you to talk with your colleagues and administrators about medication safety. It's not about placing blame-it's about learning, it's about improving, and most of all, it's about your patients.