TITLE: Task Force on Safety-Sensitive Measures to Review Medication Errors

WHEREAS, the purpose of pharmacy practice is to ensure that patients receive appropriate care and are protected from potentially dangerous medications through safety-sensitive measures; and

WHEREAS, medication errors are a well-documented problem in the United States and the cause of patient harm, including morbidity and mortality; and

WHEREAS, professionals such as airline pilots and other health care providers rely on safety-sensitive measures and embrace systems of error disclosure, analysis, and productive response, often referred to as a “just culture” approach that reviews operations rather than individuals; and

WHEREAS, the practice of pharmacy has been traditionally regulated by relying on the use of discipline and sometimes process-oriented regulations; and

WHEREAS, state boards of pharmacy would benefit from expertise and resources to transition to a more proactive, safety-sensitive, just culture environment;

THEREFORE BE IT RESOLVED that NABP convene a task force to encourage and support member state boards of pharmacy in transitioning to a just culture type of regulatory approach, which addresses the identification and resolution of medication errors through a system that implements best practices, thereby reducing medication errors and increasing patient safety; and

BE IT FURTHER RESOLVED that the task force identify resources and experts to assist state boards of pharmacy and other stakeholders in this transition, and that NABP serve as a central access point to these resources.

(Resolution passed at the 117th Annual Meeting.)