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We outline some of the causes of medication errors involving women and recommend ways that healthcare practitioners can prevent some of these errors. Patient safety has become a major concern since the November 1999 release of the Institute of Medicine (IOM) report, "To Err Is Human." Errors involving prescription medications are responsible for up to 7000 American deaths per year, and the financial costs of drug-related morbidity and mortality may be nearly $77 billion a year. The Institute for Safe Medication Practices (ISMP) collects and analyzes voluntary confidential medication error reports and makes recommendations on the prevention of such errors. This paper uses the expertise of ISMP in medication error prevention to make recommendations to prevent medication errors involving women. Healthcare practitioners should focus on areas of the medication use process that would have the greatest impact, including obtaining complete patient information, accurately communicating drug information, and properly educating patients. Although medication errors are not more common in women, there are some unique concerns with medications used for treating women. In addition, sharing of information about medication use and compliance with medication regimens have been identified as concerns. Through the sharing of information and improving the patient education process, healthcare practitioners should play a more active role in medication error reduction activities by working together toward the goal of improving medication safety and encouraging women to become active in their own care.

Managed care pharmacy is well positioned to affect change in the health care system. Through information dissemination and education, managed care pharmacists should play a more active role in medication error-reduction activities by improving the patient education process and in assisting the pharmacy community in its goal of improving patient safety.

Over the years, the Institute for Safe Medication Practices has gained a great deal of insight into the medication-use system through reports of medication errors and by performing on-site analyses at various health care organizations. Part 2 reviews the key elements of the medication-use process, contributing factors that lead to medication errors, and recommendations for consultant pharmacists that will assist long-term care facilities in preventing medication errors.

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The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

The consultant pharmacist has a vital role in the management of medications in the long-term care setting, but this activity is retrospective, and it may uncover medication errors that have already occurred. However, this process does not prevent medication errors from occurring. This first part of a two-part series will look at the underlying causes that lead to medication errors and provide recommendations for consultant pharmacists to address the potential for error.