NCC MERP Research Articles

On the integration and standardization of medication error data: taxonomies, terminologies, causes and contributing factors.

A reliable database on the causes and contributing factors of medication errors can inform strategies for their prevention. To form a single database from multiple databases requires a process of integration that both maximizes the utility of the new data and minimizes the loss of information. Unfortunately, the terminologies used by different studies and databases may limit integration; therefore, terminologies must be standardized prior to integration. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Taxonomy of Medication Errors was applied to standardize the different terminologies in 11 studies that reported the causes or contributing factors of medication errors. After standardization, 57% of the reported causes and contributing factors were integrated to form a database while 43% were not integrated because the terminologies could not be standardized or were not similar to the taxonomy. This study highlights the challenges to standardizing and integrating databases and the importance of adopting and applying a standardized terminology to record medical errors.

Frequency and Severity of Harm of Medication Errors Related to the Parenteral Nutrition Process in a Large University Teaching Hospital

To determine the frequency of medication errors, as well as the severity of harm resulting from these errors, related to the prescription, transcription, preparation, and administration of parenteral nutrition formulations. Prospective, observational study. 471-bed, academic teaching hospital. All adult and pediatric inpatients receiving parenteral nutrition between November 1, 2002 and May 31, 2004. The occurrence of incorrect prescribing practices, wrong formulation preparation, operational system errors, order entry errors related to automated technology, and incorrect administration practices were documented. In addition, the specific step in the drug process--prescription, transcription, preparation, and administration--at the time that the error occurred was noted. Harm scores, to assess the severity of the error in relation to the safety of the patient, were assigned based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). The rate of errors with parenteral nutrition was then compared with the rate of errors with other high-alert drugs, both at our institution and at a health care consortium. A total of 4730 prescriptions for parenteral nutrition were written during the study period; 74 (1.6%) were associated with a medication error. Of these errors, 1 (1%) occurred during the prescription process (and was detected before preparation), 29 (39%) occurred during the transcription process, 18 (24%) during preparation, and 26 (35%) during the administration process. Sixty-seven (91%) of the 74 errors were considered nonharmful, as defined by NCC MERP, whereas 6 (8%) contributed to or resulted in temporary harm to a patient. The rate of errors was similar between our institution and the consortium, both for parenteral nutrition formulations and for other high-alert drugs. The overall incidence of medication errors during the study was 15.6 errors/1000 parenteral nutrition prescriptions compounded. Our results demonstrate that medication errors related to the prescription, transcription, preparation, and administration of parenteral nutrition formulations occur and occasionally result in harm. Health care institutions should develop quality assurance programs to document compliance with published safe practice guidelines for parenteral nutrition.

Reliability of the assessment of preventable adverse drug events in daily clinical practice

To determine the reliability of the assessment of preventable adverse drug events (ADEs) in daily practice and to explore the impact of the assessors' professional background and the case characteristics on reliability. We used a combination of the simplified Yale algorithm and the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) scheme to assess on the one hand the causal relationship between medication errors (MEs) and adverse events in hospitalised patients and on the other hand the severity of the clinical consequence of MEs. Five pharmacists and five physicians applied this algorithm to 30 potential MEs. After individual assessment, the pharmacists reached consensus and so did the physicians. Outcome was both MEs' severity (ordinal scale, NCC MERP categories A-I) and the occurrence of preventable harm (binary outcome, NCC MERP categories A-D vs. E-I). Kappa statistics was used to assess agreement. The overall agreement on MEs' severity was fair for the pharmacists (kappa = 0.34) as well as for the physicians (kappa = 0.25). Overall agreement for the 10 raters was fair (kappa = 0.25) as well as the agreement between both consensus outcomes (kappa = 0.30). Agreement on the occurrence of preventable harm was higher, ranging from kappa = 0.36 for the physicians through kappa = 0.49 for the pharmacists. Overall agreement for the 10 raters was fair (kappa = 0.36). The agreement between both consensus outcomes was moderate (kappa = 0.47). None of the included case characteristics had a significant impact on agreement. Individual assessment of preventable ADEs in real patients is difficult, possibly because of the difficult assessment of contextual information. Best approach seems to be a consensus method including both pharmacists and physicians.

Reliability evaluation of the adapted National Coordinating Council Medication Error Reporting and Prevention (NCC MERP) index

Adapted National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index criteria were used in a study undertaken to evaluate commercial computerized provider order entry (CPOE) system impact on community hospital medication errors. This article describes: (1) adaptation of the Index, (2) classification criteria and processes used to assess the adapted Index, and (3) inter-rater reliability results. A random sample of 130 (17%) of 2251 medication safety events (MSEs) were classified based on event type, that is, adverse drug event (ADE) or potential ADE (PADE); preventability, that is, 'yes' or 'no,' and outcome severity. Event outcome severity was categorized using adapted Index categories E-I (ADEs) and B-D (PADEs). Decision rules were used for rule-based classification, while an MSE Case Review Panel used judgment-based classification when decision rules did not apply. Inter-rater reliability for both classification approaches was assessed with kappa coefficients, percentage agreement, and confidence intervals (CI). Level of agreement was substantial for both rule-based and judgment-based MSE classification for event type (6 = 0.70-0.90), preventability (6 = 0.67-0.82), and decision rule application (6 = 0.79). Rule-based agreement for ADE and PADE severity was almost perfect for discrete (6 = 0.83-0.84) and combined (6 = 0.87-0.90) Index categories. Judgment-based agreement was substantial for discrete (6 = 0.63-0.67) and combined (6 = 0.66-0.84) Index categories. The adapted Index yielded substantial agreement for event type, preventability, and severity. Adaptation of the Index to support classification of non-preventable ADEs was an important improvement.

Interrater agreement with a standard scheme for classifying medication errors

The interrater agreement for and reliability of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index for categorizing medication errors were determined. A letter was sent by the U.S. Pharmacopeia to all 550 contacts in the MEDMARX system user database. Participants were asked to categorize 27 medication scenarios using the NCC MERP index and were randomly assigned to one of three tools (the index alone, a paper-based algorithm, or a computer-based algorithm) to assist in categorization. Because the NCC MERP index accounts for harm and cost, and because categories could be interpreted as substantially similar, study results were analyzed after the nine error categories were collapsed to six. The interrater agreement was measured using Cohen's kappa value. Of 119 positive responses, 101 completed surveys were returned for a response rate of 85%. There were no significant differences in baseline demographics among the three groups. The overall interrater agreement for the participants, regardless of group assignment, was substantial at 0.61 (95% confidence interval [CI], 0.41-0.81). There was no difference among the kappa values of the three study groups and the tools used to aid in medication error classification. When the index was condensed from nine categories to six, the interrater agreement increased with a kappa value of 0.74 (95% CI, 0.56-0.90). Overall interrater agreement for the NCC MERP index for categorizing medication errors was substantial. The tool provided to assist with categorization did not influence overall categorization. Further refining of the scale could improve the usefulness and validity of medication error categorization.

Reduction in Anticoagulation-Related Adverse Drug Events Using a Trigger-Based Methodology

An initiative was undertaken by Novant Health System to address warfarin-related adverse drug events (ADEs) using lab-based patient-specific International Normalized Ratio (INR) triggers and pharmacy-based patient-specific Vitamin K triggers. The goal was to reduce ADEs related to the use of warfarin in both the inpatient and outpatient settings. Process improvements and medication management protocols were developed for patients managed with warfarin anticoagulation. During each month's seven-day sampling period, the hospital information system generated the lab and pharmacy triggers, and the clinical pharmacists used these patient-specific triggers to identify the patient charts for review. All triggered charts were reviewed. Preliminary harm classification based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was assigned by the clinical pharmacists and recorded for each patient. The system achieved reductions in ADEs related to warfarin administration on an inpatient management (45%) and outpatient management (52%) basis. Although based on inpatient facility-generated triggers, the initiative also served as a reasonable outpatient model, with improvements seen in the outpatient physician intervention groups.