Error reporting systems

Part two of the plan calls for establishing an error-reporting system. The report suggests a two-prong approach in which a national program is first implemented at the state level to detect the most serious errors. Then, a voluntary, confidential system is established to encourage individuals to report near misses. Pharmacists can participate in both activities to provide their expertise and help create such systems in their institutions. 

Barriers to medication error reporting should be eliminated and a non-punitive culture encouraged. This will allow a well-developed medication error reporting system to be developed to collect vital information for root cause analysis and risk assessment. 

Error reporting systems Provide multiple perspectives over time Reporting bias... 

In 1999, the Institute of Medicine released a report estimating that between 44,000 and 98,000 deaths occur in American hospitals each year due to medical errors. Errors which do not result in death may result in irijury or a prolonged stay with increased costs to the individual, to the hospital and the cormnunity. Most worryingly, many of these events are preventable. The main suggestion from the Institute of Medicine s report was to learn from errors and improve the system rather than blame individuals for errors implement mandatory or volimtary error reporting systems and develop strong safety leadership. These activities are also the focus of this chapter. 

Jones et al. (2008) Error Reporting System Two years Critical access hospitals Hospital Survey on Patient Safety Culture Overall perception of patient safety increased from 69% to 72% other dimensions of survey showed comparable increases... 

Health Care Human Error Reporting Systems... 

Medication Errors Reporting System. This system was developed by the Institute for Safe Medication Practice (ISMP) in 1975 and is a voluntary medication error reporting system. The system receives reports from frontline practitioners and shares its information with the pharmaceutical companies and the FDA, and is managed by U.S. Pharmacopoeia (USP). 

Procedures. Standardized error reporting system Competencies and Procedures. All members of staff given access to and training in incident reporting system Procedures. Incident reporting system should be confidential, anonymous, blame free, and non-punishable (where appropriate)... 

Figure 13.5 What different participants in a human-error reporting system give and receive in return.

All complex software contains bugs and since the source code for a package is seldom provided, an error reporting system is essential. A package used by a number of reputable users is likely to be relatively error-free but it is worth contacting several experienced users. 

Workforce Support for Data Collection and Incident Analysis Systems Few of the incident investigation and data collection systems reviewed provide any guidelines with regard to how these systems are to be introduced into an organization. Section 6.10 addresses this issue primarily from the perspective of incident reporting systems. However, gaining the support and ownership of the workforce is equally important for root cause analysis systems. Unless the culture and climate in a plant is such that personnel can be frank about the errors that may have contributed to an incident, and the factors which influenced these errors, then it is unlikely that the investigation will be very effective. 

Medication error information submitted to USP is entered into a nationally recognized repository for medication error reporting. This database serves to track, monitor, and analyze medication errors from a systems-based perspective. The USP develops educational resources and materials to disseminate best practice solutions and error-avoidance strategies to students and practitioners. 

Stimulation of development and use of medication error reporting and evaluation systems and stimulation of reporting to a national system for review, analysis, and development of recommendations to reduce and prevent medication errors... 

Medication errors have been defined in many ways, depending on research methodologies, incident reporting systems, risk management, or total quality improvement systems. USP uses the broad definition of medication error from the NCC MERP ... 

It was reported by the Institute for Safe Medication Practices (ISMP) in 2000 that fewer than 5 percent of physicians were writing prescriptions electronically. In a 2000 white paper entitled, A Call to Action Eliminate Handwritten Prescriptions within 3 Years, ISMP recommended the use of electronic prescribing by clinician order entry to reduce medication errors (ISMP, 2000). CPOE can help to reduce errors in the delivery and transcribing of orders to the pharmacy where the orders are filled. Order management can be used to control inventory and alert pharmacy staff (and even the patient) of the status of a prescription. For example, some national chain pharmacies have the capability of alerting the patient by phone or e-mail if a prescription is ready or if other action needs to be taken before the prescription can be picked up. The system should also be able to report results, such as the number of prescriptions filled, the revenue generated over a specified time, and medication error reports. 

This chapter focuses on system enhancements and the checks and balances needed to proactively prevent medication errors as pharmacists and technicians prepare, dispense, and monitor the effects of medications in all practice settings. In addition, focus is placed on the importance of determining latent failures that contribute to mediation errors by developing effective medication error reporting programs to discover how latent failures occur and how they can be prevented. 

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