APMS News & Updates

Stay up-to-date with the lastest news and updates direct from Alliance for Patient Medication Safety®.

APMS® Activity for your Peer Review Meetings

The Ethics of Managing a Medication Error
January 4, 2017

Analyzing your QRE data and taking the necessary steps to prevent medication errors are only two parts of a robust safety and quality program.   When the error reaches a patient, there are usually additional considerations to ethically manage the event.  At a fundamental level, ethical principles support the optimal culture of safety that all pharmacies strive for.  These include respect for patient autonomy, truthfulness, fidelity, beneficence, and non-maleficence.  A broader discussion of each of these is beyond the scope of this article; however, many references are available online for further study.  Knowing the ethical principles is a starting point for all pharmacists and technicians.  Ethical behaviors are the application of these principles. 

The following hypothetical case study involves a medication error that reached the patient.  After reviewing the details of the case, readers are asked to click on the Survey Monkey link at the right to select how you would handle this in your pharmacy. Answers are anonymous. Aggregate responses and expert commentary will be reported to you in a future newsletter.  Readers are also encouraged to discuss this case in your QA meetings and discuss the readiness of your employees to know and act in an ethical manner.

APMS® Announces Gaps in Care Residency Incentive Grant Program!

August 16, 2016

Health care providers, including pharmacists, often identify gaps in a patient’s care (not treating to guidelines or to best practices) and errors or omissions in the care provided (made by themselves or other practitioners). Communicating with the health care team to resolve gaps, errors, and omissions is critical to improving patient outcomes and improving the quality of care delivery processes. Error reporting and aggregation is done for the prescription filling process through APMS’s® PQC® program, and now there is protected way for pharmacists to aggregate direct patient care related error data and look for trends. As quality metrics for pharmacist services shift from being product-focused to health outcome-focused, it is important to understand workflow and care delivery processes to optimize patient outcomes. By creating a process within a Federally Listed Patient Safety Organization(PSO), data can be aggregated, analyzed, and shared to identify common problems and solutions using quality improvement principles in a protected environment.

In 2014, the Alliance for Patient Medication Safety® (APMS®) PSO developed a Clinical Process Related Events Report Form (CPREF) to document gaps in clinical care the pharmacist identifies when coaching a patient with diabetes and gaps in the pharmacist patient care process. After piloting the form, it was converted to an online Clinical Process Related Events Reporting Portal, Gaps in Care - Diabetes, a tool for quality improvement when managing patients with diabetes. The data collected and the space in which the team works to close the gaps in care will be protected by working with the APMS® PSO, thereby fostering a culture of quality improvement. 

View Complete Grant Program      

Alliance for Patient Medication Safety's® continued listing as a Patient Safety Organization

March 1, 2016
The Agency for Healthcare Research and Quality (AHRQ) has accepted the APMS® certifications as a federally listed Patient Safety Organization (PSO) for another three years.

The Patient Safety Act allows healthcare providers that contract with PSOs to share information for learning purposes without jeopardizing the protection of that data. The potential for legal exposure impeded patient safety data reporting in the past. A change in culture, in addition to the advent of patient safety organizations, has encouraged pharmacies to study and report this data in growing numbers.

Thousands of pharmacies work with APMS® to implement a quality assurance program and report their errors and near misses through the Pharmacy Quality Commitment (PQC®) program. Pharmacies within the PSO learn from their own data and from aggregate data of other users within the PSO. The APMS® patient safety experts create continuing education and learning modules based on reviewed data so that members can make timely changes in processes and workflow patterns to increase patient safety.

"As part of Medicare Part D, all pharmacies must have and maintain effective quality assurance (QA) programs program that help them develop and maintain continuous quality improvement," said Tara Modisett, executive director for APMS®. "The PQC® program provides an easy way to meet the QA requirements and gives the pharmacy valuable tools and feedback to help pinpoint weak areas in the dispensing process. In addition, by working with a patient safety organization, our pharmacies can study their patient safety data in order to maintain the highest quality of service and can rest easy knowing that the data is protected."