Voluntary Medication Error Reporting Program in a Japanese National University Hospital

The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems

Background: Population-based studies from several countries have constantly shown excessively high rates of medication errors and avoidable deaths. An efficient medication error reporting system is the backbone of reliable practice and a measure of progress towards achieving safety. Improvement efforts and system changes of medication error reporting systems should be targeted towards reductions in the likelihood of injury to future patients. However, the aim of this review is to provide a summary of medication errors reporting culture, incidence reporting systems, creating effective reporting methods, analysis of medication error reports, and recommendations to improve medication errors reporting systems. Methods: Electronic databases (PubMed, Ovid, EBSCOhost, EMBASE, and ProQuest) were examined from 1 January 1998 to 30 June 2020. 180 articles were found and 60 papers were ultimately included in the review. Data were mined by two reviewers and verified by two other reviewers. The search yielded 684 articles, which were then reduced to 60 after the deletion of duplicates via vetting of titles, abstracts, and full-text papers. Results: Studies were principally from the United States of America and the United Kingdom. Limited studies were from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia, and Egypt. Detection, measurement, and analysis of medication errors require an active rather than a passive approach. Efforts are needed to encourage medication error reporting, including involving staff in opportunities for improvement and the determination of root cause(s). The National Coordinating Council for Medication Error Reporting and Prevention taxonomy is a classification system to describe and analyze the details around individual medication error events. Conclusion: A successful medication error reporting program should be safe for the reporter, result in constructive and useful recommendations and effective changes while being inclusive of everyone and supported with required resources. Health organizations need to adopt an effectual reporting environment for the medication use process in order to advance into a sounder practice.

A medication error reporting scheme: analysis of the first 12 months

Aims and Method

A new medication error reporting scheme (‘Safemed’) was introduced within the East Kent NHS and Social Care Partnership Trust. All medication incidents reported using this system in the first year were analysed by the Chief Pharmacist.

Results

Over a 12-month period a total of 66 incidents were reported through Safemed, compared with 55 incidents under the previous system. The low level of reporting made detailed statistical analysis and drawing meaningful conclusions problematic. There was a large variability in reporting between similar sites.

Clinical Implications

The low level of reporting was associated with cultural factors, in particular the failure to fully implement a ‘no blame’ culture. Until such a culture is established, reporting will remain variable and a systems approach to preventing medication errors will not be adopted, leading to significant clinical risk.

Perceptions and Attitudes towards Medication Error Reporting in Primary Care Clinics: A Qualitative Study in Malaysia

Objective

To explore and understand participants’ perceptions and attitudes towards the reporting of medication errors (MEs).

Methods

A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach.

Results

Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter’s burden and benefit of reporting also were identified.

Conclusions

Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use.

Development of an online incident-reporting system for management of medical risks at hospital

  To minimize their occurrence, it is important to gather and analyze data regarding cases of not only medical accidents but also of incidents involving potential harm to patients. In gathering data, we have separated reporting between the details of such incidents and information about their occurrence. We have implemented a system involving a first report to achieve prompt notification and a second report to provide details. An online report input system has been established taking into consideration both ease of input and promptness of information sharing. We discuss the input of the first and second reports in a total of 951 cases over a period of 6 months. From the data regarding the timing of the first report, 307 and 789 cases were reported within 24 h and 48 h, respectively, indicating that the first report was input mostly without delay in accordance with the operational guidelines. On the other hand, it took 14 days to surpass a second report rate of 80%. Cases that took more than 2 weeks to be reported would likely have gone unreported had there not been a first report to indicate and confirm that an incident had even occurred. Investigation is needed, especially for problematic cases, so we assume that discovering important incidents via the first report has been successful. In addition, details of incidents can be input into this system in free-text, yielding information that cannot be acquired with multiple choice input as in standard reporting systems.

Improving the quality of drug error reporting

BACKGROUND

Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections.

AIM

The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital.

METHODS

A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi-disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting.

RESULTS

The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems-based. Staff felt obliged to report but rarely received feedback. IMPLICATIONS AND CONCLUSION: Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate learning and foster supportive actions. It can also be feasible in routine practice. Such an approach should be examined through multi-centred evaluation.

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs

BACKGROUND

External reporting of medical errors a adverse events enables learning from the errors of others in the pursuit of systems-level improvements that can prevent future errors. It is logical to presume that medication errors involving the use of anticoagulants, among the most frequently cited product classes involved in harmful medication errors, would be captured in a variety of patient safety reporting programs.

METHODS

Data on reported errors involving the anticoagulant heparin were reviewed, compared, and aggregated from the databases of three large patient safety reporting programs-MEDMARX, the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, and the University Health System Consortium, together representing more than 1,000 reporting organizations for 2005

RESULTS

Approximately 300,000 medication errors and near misses were reported to the programs, and 10,359-a mean of 3.6% (range, 3.1%-5.5%)-involved heparin products. The proportion of heparin-related reports that involved patient harm ranged from 1.4% to 4.9%. The phase of the medication use process cited most frequently in harmful events was the administration phase (56% of errors leading to harm), followed by the prescribing phase (19% of errors leading to harm).

DISCUSSION

This study represents the first attempt by these three large reporting systems to combine data on a single clinical process. The consistent patterns evident in the reports, such as the percentage of all medication errors that involved heparin, suggests that reporting programs, at least for common events such as medication errors, may reach a point of diminishing returns in which aggregating more reports of a certain type yields no additional insight once a large volume of similar events is captured and analyzed.

Is the principle of a stable Heinrich ratio a myth? A multimethod analysis

BACKGROUND

Safety improvements are sometimes based on the premise that introducing measures to combat minor or no-harm incidents proportionately reduces the incidence of major incidents involving harm. This is in line with the principle of the Heinrich ratio, which asserts that there is a relatively fixed ratio between the incidence of no-harm incidents, minor incidents and major incidents. This principle has been advocated as a means of targeting and evaluating new safety initiatives.

RESEARCH METHODOLOGY

Both thought experimentation and analysis of empirical data were used to examine the plausibility of this principle. A descriptive statistical analysis was carried out using triangle plots to display the relative frequencies of the occurrence of safety incidents classified as minor, moderate or severe.

FINDINGS

Thought experiments indicated that the principle of a fixed Heinrich ratio has a dubious logical foundation. Analysis of emergency department attendance and studies of medication errors demonstrated marked variation in the relative ratios of different outcomes. Triangle plots of UK road traffic accident data revealed a hitherto unrecognized systematic pattern of change that contradicts the principle of the Heinrich ratio.

INTERPRETATION

This study of the principle of a fixed Heinrich ratio invalidates it: introducing measures to reduce the incidence of minor incidents will not inevitably reduce the incidence of major incidents pro rata. Any safety policies based on the assumption that the Heinrich ratio is true need to be rethought.

The need for organizational change in patient safety initiatives

OBJECTIVES

This study describes a computer simulation model that has been developed to explore organizational changes required to improve patient safety based on a medication error reporting system.

METHODS

Model parameters for the simulation model were estimated from data submitted to the MEDMARX medication error reporting system from 570 healthcare facilities in the U.S. The model's results were validated with data from the Pittsburgh Regional Healthcare Initiative consisting of 44 hospitals in Pennsylvania that have adopted the MEDMARX medication error reporting system. The model was used to examine the effects of organizational changes in response to the error reporting system. Four interventions were simulated involving the implementation of computerized physician order entry, decision support systems and a clinical pharmacist on hospital rounds.

CONCLUSIONS

Results of the analysis indicate that improved patient safety requires more than clinical initiatives and voluntary reporting of errors. Organizational change is essential for significant improvements in patient safety. In order to be successful, these initiatives must be designed and implemented through organizational support structures and institutionalized through enhanced education, training, and implementation of information technology that improves work flow capabilities.

Understanding safer practices in health care: a prologue for the role of indicators

OBJECTIVES

Patient safety and safer practices are central themes to many national strategies for accountability. The multinational Quality Indicator Project (QI Project) database is used to identify patterns of indicator use to measure safety of care in Asia, Europe, and the USA. The second objective is to assess, within the context of an indicator project, the usefulness of indicators to measure errors or mishaps.

DESIGN AND SETTING

This descriptive study retrospectively analyses indicator use patterns among hospitals in Asia, Europe, and the USA. The QI Project database is used for the 1999-2002 period. Statistical testing (P-value) of the differences in use percentages across five countries is based on 'country' rather than 'hospital' as the unit of analysis.

RESULTS

There was a significant increase in overall QI Project indicator use worldwide between 1999 and 2002. The average change in use was 6.8% for safety indicators and 4.2% for all other indicators. When analysed by country (USA, Austria, Belgium, UK, and Taiwan), the average increases in use percentage were highest in Taiwan and Belgium. When the country-specific differences were tested for significance, Taiwan showed the largest (and statistically significant) increase in safety indicator use between 1999 and 2002 (P<0.0001). In the USA, the rates of safety indicator use have decreased (P=0.0502) during the same time period.

CONCLUSION

This paper identifies, perhaps for the first time, how traditional indicators of hospital performance are being used to understand a hospital's performance and associated safety of care. Although the study's time frame is limited to 3 years, the findings seem to suggest that the interest in using these traditional indicators as proxies for safer practice measures is increasing among the QI Project participants worldwide. The challenge of using inherently value-free indicators as indicators of safety (hence de facto labelled as 'error' focused) should be further studied.