Medication safety remains a critical topic for healthcare providers and consumers. Among the issues being focused on in 2009 by the Joint Commission include anticoagulant errors, the increasing impact of multidrug-resistant organisms, and the appropriate use of antimicrobials, medical reconciliation, and documentation.

The Joint Commission’s National Patient Safety Goal was required to be implemented by January 1, 2009. The focus of this goal is to decrease the likelihood of harm from anticoagulation medications. It requires the standardization of processes for prescribing, dispensing, monitoring, and educating patients on the medications.

Successful implementation of these processes to meet the requirements of the goal is both significant and complex. Medication errors concerning heparin continue to occur, which has prompted the convening of consensus conferences and summits on IV drug delivery and safety. These have been sponsored by the American Society of Health System Pharmacists, the Institute of Safe Medication Practices, and others including representatives from academia, industry, and hospital pharmacy practices.

A clinical case for appropriate and effective use of antimicrobials has resulted from the increased impact of multidrug-resistant organisms. Antibiotic stewardship programs are being implemented to oversee the processes of prescribing and monitoring antimicrobials as part of the greater good of the healthcare community. These stewardship programs have often demonstrated significant reversals in resistance trends as a result.

Another focus of the National Patient Safety Goal is improved medication reconciliation and documented communications, critical to mitigating risk and maintaining safety. Among the changes in 2009 includes the requirement that admission home medication lists include dose, frequency, and route. There must also be documentation that communication has occurred between transferring and receiving units. Upon discharge from the facility, there must be documented evidence that communication of the medication list has been provided to the patient, family, and the next care provider.

Ensuring that each patient receives the correct medications in the right doses at the right times is dependent upon thorough communication. The sharing of every aspect of patient care across all involved disciplines of those working collaboratively would be the ideal to guarantee the patient’s rights to effective, safe, quality care.

The progress of medication-related technology continues at a rapid pace. These technologies significantly change the practices of healthcare practitioners, though they are often challenged with the optimal implementation and use of the tools. The Joint Commission’s 42nd Sentinel Event Alert of December 2008 urges that care be taken when making decisions related to new technology. Understanding the impact the technology will have on patient safety and quality of care relating to the implementation of the new processes must be addressed.

These medication-safety issues, among others, continue to be significant as the focus of the Joint Commission on robust process improvements challenged hospitals in 2009. Medication safety is expected to be impacted as hospitals review and improve their processes to achieve and sustain desired outcomes.