Medication Error Reporting System Research Articles

PDG54 Establishment and Implementation of Medication Error Reporting in Community Pharmacies in Southern India

Medication Errors (MEs) may occur at any stage of medication utilization process which can lead to undesirable health consequences. Medication errors in community pharmacies have serious consequences for patients, and certain populations may be at increased risk for harm, such as chronically ill and elderly patients with comorbidities and Poly Pharmacy. Hence, we aimed to establish and inculcate the culture of medication error reporting system (MERS) among community pharmacist and assess and minimize the nature and extent of MEs. A Prospective Observational study conducted in private community pharmacies In our southern Indian province Prescriptions of study participants were reviewed on a daily basis, the identified MEs were documented in the suitable documentation form and also data base for easy retrieval of data. Out of 868, 514 study participants were enrolled during study. A total of 1416 medication errors were identified in 514 enrolled study participants. Errors were found to be more, were prescription errors [1242 (87.71%)] and procurement errors. [157 (11.08%)]. The personnel involved in error were Physicians [493 (78.01%)] and patients [79 (12.50%)]. The major therapeutic classes that were implicated in MEs, belongs to analgesics / antipyretics (39.94%) followed by antibiotics (20.74%), and antihistamines accounting for 16.32% were majorly involved in MEs [705 (49.78%)] and the potential causation that lead to error was regular practice among physician [513 (73.81%)] and peak hours workload among pharmacist [60 (8.63%)]. The MEs outcome categorization is according National National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), In this study, majority of errors were category C 88.14% (1248), followed by, category A 11.09% (157) and category D 0.78% (11). The reporting system was inculcated in the community settings in order to monitor and prevent the MEs. The study finding indicated that medication errors. occur in all levels of drug treatment.

Exploration of Nurses' Knowledge, Attitudes, and Perceived Barriers towards Medication Error Reporting in a Tertiary Health Care Facility: A Qualitative Approach.

Medication error reporting (MER) is an effective way used to identify the causes of Medication Errors (MEs) and to prevent repeating them in future. The underreporting of MEs is a challenge generally in all MER systems. The current research aimed to explore nurses’ knowledge on MER by determining their attitudes towards reporting and studying the implicated barriers and facilitators. A total of 23 nurses were interviewed using a semi-structured interview guide. The saturation point was attained after 21 interviews. All the interviews were tape-recorded and transcribed verbatim, and analysed using inductive thematic analysis. Four major themes and 17 sub-themes were identified. Almost all the interviewees were aware about the existence of the MER system. They showed a positive attitude towards MER. The main barriers for MER were the impacts of time and workload, fear of investigation, impacts on the job, and negative reactions from the person in charge. The nurses were knowledgeable about MER but there was uncertainty towards reporting harmless MEs, thus indicating the need for an educational program to highlight the benefits of near-miss reporting. To improve participation strategies, a blameless reporting culture, reporting anonymously, and a simplified MER process should be considered.

Medication Error Reporting: Underreporting and Acceptability of Smartphone Application for Reporting among Health Care Professionals in Perak, Malaysia.

Background and objectivesIn Malaysia, the national voluntary non-punitive Medication Error Reporting System (MER-S) has been available since 2009, with compiled reports indicating the underreporting of various medication errors (ME). This survey intends to determine the ME reporting practice among healthcare professionals and the acceptance of ME reporting by utilising smartphone application if it is available.DesignA cross-sectional survey was conducted for two months in 2017 among doctors and pharmacists in publicly funded healthcare facilities in Perak, Malaysia. The survey was distributed through various professional WhatsApp chat groups, and reminders were sent twice to the respondents.ResultsA total of 334 doctors and pharmacists responded to the survey; the majority were pharmacists (61.7%) with a median age (in years) of 32 (interquartile range (IQR) 29-36) and work experience (in years) of 7.5 years (IQR 5-11). The rate of respondents being aware of the MER-S and having encountered ME at the workplace was high, at 73.4% and 96.1%, respectively. However, only 44.8% reported using the system. The reason hindering them from reporting ME was primarily being in a busy and hectic work environment. Pharmacists were more likely to report ME compared to doctors (adjusted odds ratio (adj OR) 10.51; 95% Confidence interval (CI): 5.34, 20.6), especially pharmacists who had frequent encounters with ME at work (adj OR 2.84; 95% CI: 1.70, 4.81) and who perceived that ME can be handled well (adj OR 3.52; 95% CI: 1.93, 6.44). They were more likely to report ME. A majority (90.7%) had downloaded one or more digital medical applications to aid their work. The speed of Internet connectivity at the workplace was rated as “fast” or “good” among 136 (40.7%) respondents but among 130 (38.9%), it was “average.” The percentage of doctors and pharmacists that would report ME by utilising a smartphone application was 86.5% if one is available, and they preferred an application with a user-friendly interface, anonymity, and limited data-entry requirements.ConclusionDoctors and pharmacists were aware of MER-S and willing to report when they encountered ME. However, less than half of the respondents had used the system. With the primary concern of ME underreporting in a busy and hectic work environment, an alternative smartphone ME reporting application can be developed to complement the current MER-S considering that the respondents had positive responses to this method.

Development of medication errors reporting system: an object-oriented approach

Medication errors pose a serious threat in the healthcare industry. This paper aims at developing a medication error reporting system (MERS) that enables medical professionals to anonymously report medication errors by opening a case in the MERS database. The object-oriented approach was used to analyse and design the MERS system. The systems requirements are first gathered with the use of questionnaires and interviews with practitioners; then, analysed based on unified modelling language techniques such as use case, class, and sequence diagrams. Implementing a MERS into hospitals allows medical professionals to analyse error patterns by referencing archived cases in the database; thus enhancing clinical practices that prevent future errors.

Medication errors reported to the National Medication Error Reporting System in Malaysia: a 4-year retrospective review (2009 to 2012)

Reporting and analysing the data on medication errors (MEs) is important and contributes to a better understanding of the error-prone environment. This study aims to examine the characteristics of errors submitted to the National Medication Error Reporting System (MERS) in Malaysia. A retrospective review of reports received from 1 January 2009 to 31 December 2012 was undertaken. Descriptive statistics method was applied. A total of 17,357 MEs reported were reviewed. The majority of errors were from public-funded hospitals. Near misses were classified in 86.3% of the errors. The majority of errors (98.1%) had no harmful effects on the patients. Prescribing contributed to more than three-quarters of the overall errors (76.1%). Pharmacists detected and reported the majority of errors (92.1%). Cases of erroneous dosage or strength of medicine (30.75%) were the leading type of error, whilst cardiovascular (25.4%) was the most common category of drug found. MERS provides rich information on the characteristics of reported MEs. Low contribution to reporting from healthcare facilities other than government hospitals and non-pharmacists requires further investigation. Thus, a feasible approach to promote MERS among healthcare providers in both public and private sectors needs to be formulated and strengthened. Preventive measures to minimise MEs should be directed to improve prescribing competency among the fallible prescribers identified.

National and Local Medication Error Reporting Systems—A Survey of Practices in 16 Countries

To explore the existence and characteristics of national and local medication error reporting (MER) systems and to describe national medication safety experts' perceptions of a good and effective MER system and barriers to reporting. In a descriptive cross-sectional study, 32 medication safety experts were identified through member organizations of the International Pharmaceutical Federation in 88 countries and other professional organizations in 3 additional countries. These experts were invited to participate in an online survey. Sixteen national medication safety experts from different countries participated in the study (response rate, 50%). A national (n = 5) or local (n = 6) MER system existed in 11 of these countries. In 5 countries, no MER system existed. The most common features of the MER systems were confidentiality of the reported information and providing feedback to those involved in reporting. Most experts perceived that a good and effective MER system was characterized by the opportunity to learn from errors by those involved in reporting, having a nonpunitive approach to reporting, and ease of use. They also perceived that a blame culture, lack of time, training, and coordination of reporting were the main barriers to reporting. Blame culture, a lack of time, training and coordination of reporting continue to be the major barriers to reporting. Learning from errors and having a nonpunitive approach to reporting were thought to be the most critical features of a MER system. Difficulties in identifying national medication safety experts indicates a need for promoting international networking of medication safety experts and bodies for sharing information and learning from others.

Pediatric Blood And Marrow Transplantation (BMT) Medication Error Reporting System (MERS): An Approach to Improving Quality Of Care Of Pediatric BMT Recipients

Pediatric Blood And Marrow Transplantation (BMT) Medication Error Reporting System (MERS): An Approach to Improving Quality Of Care Of Pediatric BMT Recipients

Re-engineering the medication error-reporting process: removing the blame and improving the system.

A hospital's change from a traditional, multitiered incident-reporting system for medication errors to a standardized, nonpunitive medication-use variance process is described. After weaknesses were identified in the hospital's system for reporting and evaluating medication errors, a multidisciplinary task force was formed to redesign the hospital's medication error-reporting system. Its guiding principles were as follows: anonymity and freedom from punitive action are essential for increasing the number of reports, rating medication errors facilitates identification of areas for system improvement, potential errors provide valuable insight into the system's vulnerabilities, and timely review of reports enables rapid systematic correction. To support the intended nonpunitive culture, the term medication-use variance was used in lieu of medication error for any unplanned event that deviates from the intended course of prescribing, dispensing, administering, or monitoring medications. A one-page medication-use variance report was developed that prompted the reporter for key data elements, including root causes, patient outcomes, and possible ways to prevent similar incidents. The most difficult decision for the task force was deciding whether the process should be anonymous. After getting the support of the medical-legal counsel and the quality improvement department for an anonymous reporting process, the task force agreed to test it in the department of pharmacy and in three patient units in September 1998. A paper-driven reporting process was selected initially because an electronic system would not be truly anonymous. The number of reports from these units increased compared with historical trends, and for the first time potential errors were reported. The report form was easy to use and improved the interpretation of reports. Despite these positive results, task force members remained divided on the issue of anonymity but ultimately embraced the nonpunitive culture. In the first six months following hospitalwide implementation, the number of events captured increased more than fivefold; it continues to increase. The resulting database serves as a trigger for quality improvement efforts and a measure of their effectiveness. The redesign of the medication error-reporting process served as the impetus for a change in the organizational culture surrounding medication errors.

A 3-Year Commitment–Adventure

The first time a person is approached to run for a leadership position in a charitable or professional organization, he or she is compelled to think, “How much of a commitment will this be?” When one becomes involved on the presidential track at the national level of our organization, CSHP, the commitment is 3 years of service on the Executive Committee — as President-Elect, President, and Past President. The term “commitment” is defined in the Concise Oxford Dictionary as follows: • an engagement or obligation that restricts freedom of action • a pledge or undertaking. I’m sure that many of my predecessors (Kelly Babcock, Donna Pipa, Bob Nakagawa, Robin Ensom, Nancy Roberts, and Larry Legare, among others) would concur that the first definition does occasionally hit us smack between the eyes during that 3-year CSHP executive term. However, I know that they all accepted the commitment and responsibility because of the second definition — the “pledge”. People who follow the path of becoming CSHP President do so as a pledge to the membership, to the profession, and to the Society. Each individual who takes on this role wants to better our professional practice. Becoming involved at this level of leadership provides the opportunity to “make a difference”, and taking this pledge introduces one to a 3-year adventure complete with expected and unexpected challenges. In view of the recent changes in our executive “line-up”, it may be helpful for CSHP members to learn about the responsibilities that your executive officers carry for their 3-year terms. Each new presidential officer is assigned a portfolio that is carried throughout the 3 years of service on the Executive Committee. These 3 portfolios are designed to even out the workload that was once assigned primarily to the President. The portfolios also reflect CSHP’s Vision and keep responsibilities directed toward achieving the Vision. The Vision Liaison Officer is responsible for all initiatives directed at achieving CSHP’s Vision. Committees, task forces, and initiatives that fall under the guidance of this portfolio include Educational Services, Pharmaceutical Care Advisory, Resolutions, Strategic Planning, Pharmacist Prescribing, Seamless Care, Home Health Care, and, most recently, coordination of the decision process for a potential change in the Society’s name. The External Liaison Officer is responsible for all CSHP activities that occur in collaboration with government, faculties of pharmacy, professional organizations, and patient groups with which CSHP may collaborate. The presidential officer responsible for this portfolio must always ensure that CSHP’s external activities are in tune with CSHP’s Vision. Committees, task forces, and CSHP representatives and liaisons falling under the guidance of this portfolio include Drug Labelling and Packaging, Government and Health Policy Planning, Public Relations, Pharmacy Specialty Networks, Pharmacy Technicians, Medication Error Reporting System, Entry-Level PharmD Program, CAPSI–CSHP Poster Competition, and representatives and liaisons to more than 20 organizations, committees, and boards outside of CSHP (e.g., Canadian Pharmacists Association, American Society of HealthSystem Pharmacists, Association of Faculties of Pharmacy of Canada, National Association of Pharmacy Regulatory Authorities, Canadian Association of Pharmacy Students and Interns, Canadian Association of Pharmacy Technicians, and Pharmacy Examining Board of Canada). The Internal Liaison Officer is responsible for all internal CSHP activities that directly or indirectly bring the Society closer to achieving the goals set out in its Vision. Committees, task forces, and representation that fall under the guidance of this portfolio include Awards, Bylaws, Branch Web Site Development, Membership, Standards and Publications, Research, Bulk Compounding Guidelines Review, Standards of Practice Review, Latex Allergies, Review of CSHP National Committee/Task Force Structure and Method of Business, Board of Fellows, and the Canadian Hospital Pharmacy Residency Board. The “pledge” made by all volunteers who take on this level of CSHP leadership is fulfilled within the particular officer’s portfolio but also involves sharing in the decisionmaking of the other officers on the Executive Committee. Although the presidential officers’ responsibilities differ in nature, the Executive Committee (which includes the Executive Director, the Director of Finance, and the 3 presidential officers) always works as a team. This creates, as Kelly Babcock frames it, “a ton of email”; however, the end result is coordinated actions and initiatives that benefit the membership, the profession, and the Society. Restriction of freedom? Yes, sometimes. A pledge? Always. An adventure? You’d better believe it!