Field Test Results of a New Ambulatory Care Medication Error and Adverse Drug Event Reporting System—MEADERS

John Hickner; Atif Zafar; Grace M. Kuo; Lyle J. Fagnan; Samuel N. Forjuoh; Lyndee M. Knox; John T. Lynch; Brian Kelly Stevens; Wilson D. Pace; Benjamin N. Hamlin; Hilary Scherer; Brenda L. Hudson; Caitlin Carroll Oppenheimer; William M. Tierney

doi:10.1370/afm.1169

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Reporting systems and research
Susan M Dovey

Published on: 25 November 2010
Improving patient safety: Lessons from the world�s largest national database
Aziz Sheikh

Published on: 11 November 2010
Important work on ambulatory safety reporting
Tejal Gandhi

Published on: 10 November 2010

Published on: (25 November 2010)

Reporting systems and research
Susan M Dovey, Dunedin, New Zealand
This paper adds to an important body of work about patient safety in primary care coming from the US, whose primary care physicians were the world’s early participants in patient safety research, and instrumental in defining what that term (‘patient safety’) means for patients cared for outside hospitals. Reporting systems research has become dominant in the primary care patient safety research world, perhaps because it...
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This paper adds to an important body of work about patient safety in primary care coming from the US, whose primary care physicians were the world’s early participants in patient safety research, and instrumental in defining what that term (‘patient safety’) means for patients cared for outside hospitals. Reporting systems research has become dominant in the primary care patient safety research world, perhaps because it pragmatically serves as an intervention as well as a research tool. Reporting systems, where providers recount the details of incidents they observe and consider unsafe to patients, provide invaluable insights about the more serious and rare threats to patient safety and give opportunities for clinicians to reflect on care processes they might modify for the good of their patients. I was encouraged to learn from this paper that primary care providers in the US are now quite comfortable with using a web-based reporting system. I am less encouraged by the implication of this report that such work still must be carried out within the realm of “research”, rather than having patient safety reporting systems integrated into usual clinical practice. I am further discouraged that so many participants in this study experienced qualms about engaging in the reporting system, fearing personal repercussions. Many reporting systems throughout the world remain “top down” affairs, designed first for hospital managers and adapted for primary care clinicians. This is one of the reasons that community based general practice contributes only a tiny proportion (less than 1%) of safety incidents reported to the UK’s National Patient Safety Agency,1 despite more health care contacts occurring in general practice in the UK than in any other setting (approximately 1.3% of the UK population visit a GP every day2), as in the US.3 For reporting systems to work well in fulfilling their primary function of improving patient safety, they need to be designed so that they are safe for people who make reports and they need to be able to produce practical, implementable strategies for making healthcare safer in practice. The MEADERS system seems to do this, although it does collect reporters’ names, which suggests personal repercussions are possible. A focus on prescribing has characterised patient safety research for at least the last 10 years, and this is probably completely appropriate, because, as these authors state, prescribing is a core function of primary care practices, and one fraught with dangers. However, it is also the easiest to understand, the easiest to define, and the area that has attracted the most investment for longest, internationally. The more murky areas of clinical practice, such as making the correct diagnosis in a timely manner, communicating effectively across teams, and managing the implementation of public policies that don’t work well for individual patients are all no doubt on this research team’s agenda!
Competing interests: None declared
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Competing Interests: None declared.
Published on: (11 November 2010)

Improving patient safety: Lessons from the world�s largest national database
Aziz Sheikh, Edinburgh, UK
Other Contributors:
Online invited comment submitted to Annals of Family Medicine
Improving patient safety: Lessons from the world’s largest national database
Sukhmeet Singh Panesar and Aziz Sheikh
Sukhmeet Singh Panesar Clincial advisor to the Chairman National Patient Safety Agency, London, UK
Aziz Sheikh Professor of Primary Care Research & Development, Centre of Population Health Sciences: GP Se...
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Online invited comment submitted to Annals of Family Medicine
Improving patient safety: Lessons from the world’s largest national database
Sukhmeet Singh Panesar and Aziz Sheikh
Sukhmeet Singh Panesar Clincial advisor to the Chairman National Patient Safety Agency, London, UK
Aziz Sheikh Professor of Primary Care Research & Development, Centre of Population Health Sciences: GP Section, University of Edinburgh, Edinburgh, UK
Correspondence to: aziz.sheikh@ed.ac.uk
Improving patient safety: Lessons from the world’s largest national database
The high frequency of medical errors and the associated disease burden resulting from iatrogenic harm remains an important challenge for healthcare systems globally.[1] Medication related harm is a particularly important problem and given that family practice is the setting in which most healthcare encounters and prescribing now takes place, it is imperative that we better appreciate the epidemiology of such errors and develop effective interventions for preventing the risk of such – potentially avoidable – harm.[2] There are a number of strategies that need simultaneously to be pursued, these including greater use of reporting systems.[1]
It was over a decade ago now that we first called for the development of national databases of errors and it is heartening to see that in the intervening period there has been substantial progress in many parts of the world, including now in the US.[3][4][5] The most notable development perhaps has taken place in the UK (England and Wales), where a national incident reporting system, The Reporting and Learning System, has been developed. Since its launch in 2003, it has accrued over five million individual reports of patient safety incidents. This has led to a number of novel important insights that are helping to shape national policy – for example, the recognition of the risks of bone cement implantation syndrome associated with use of cement in hip fracture surgery and the potential for IT-based interventions to reduce many cases of drug allergy related morbidity.[6][7]
There have however also been a number of challenges with our UK-based experiences that warrant further international reflection and debate.[4] Despite the overall volume of reporting (discussed above), we are aware that reporting remains the exception rather than the norm leading to major difficulties in undertaking any meaningful epidemiological work using these data and the related risk of drawing potentially biased inferences. In keeping with the MEADERS experience, this is, at least in part, due to concerns about workload and risk of repercussion, but also because long- term engagement is dependant on developing a mutually reciprocal arrangement in which contributions are valued and seen to be valued. We have also struggled with poor quality of reporting, which often leads to more questions than answers. That said, it is salutary to note that we are already struggling with the existing volume of material found in these reports, particularly in the absence of established automated techniques to interrogate these largely free-text based reports.[1]
Despite these challenges, we overall continue to believe that, in the fullness of time, databases like MEADERS have the potential to emerge as a major resource both for initiating local reflective practice and offering important new insights on how best to improve patient safety in primary care (and beyond). Given the progress that is now being made internationally, it would we suggest now make sense to develop opportunities to share lessons from our related, but unique national experiences. A task for the World Health Organization’s World Alliance of Patient Safety, perhaps?
References [1] Hurwitz B, Sheikh A (eds.). Health care errors and patient safety: Oxford: Wiley Blackwell, 2009,
[2] Royal S, Smeaton L, Avery AJ, Hurwitz B, Sheikh A. Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis. Qual Saf Health Care. 2006; 15: 23-31
[3] Sheikh A, Hurwitz B. A national database of medical error. J R Soc Med. 1999; 92: 554-55
[4] Panesar SS, Cleary K, Sheikh A. Reflections on the National Patient Safety Agency's database of medical errors. J R Soc Med 2009; 102: 256-8.
[5] Hickner J, Zafar A, Kuo GM, Fagnan LJ, Forjuoh SN, Knox LM, et al. Field test results of a new ambulatory care medication error and adverse drug event reporting system--MEADERS. Ann Fam Med 2010; 8: 517-25
[6] Panesar SS, Cleary K, Bhandari M, Sheikh A. To cement or not in hip fracture surgery? The Lancet 2009; 374: 1047-49 [5] Cresswell KM, Sheikh A. Information technology-based approaches to reducing repeat drug exposure in patients with known drug allergies. J Allergy Clin Immunol. 2008; 121: 1112-17
Competing interests: None declared
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Competing Interests: None declared.
Published on: (10 November 2010)

Important work on ambulatory safety reporting
Tejal Gandhi, Needham, MA
This is an interesting and important article on implementing a medication safety reporting system in the ambulatory setting. Safety reporting is very uncommon in ambulatory care, and more work such as this needs to be done to find out how best to implement reporting so that it is quick and easy, while useful at the same time. In addition, it will be important to expand beyond medication safety since other ambulatory safet...
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This is an interesting and important article on implementing a medication safety reporting system in the ambulatory setting. Safety reporting is very uncommon in ambulatory care, and more work such as this needs to be done to find out how best to implement reporting so that it is quick and easy, while useful at the same time. In addition, it will be important to expand beyond medication safety since other ambulatory safety issues (such as missed and delayed diagnosis) may be more prevalent. In addition, this paper highlights the importance of creating a culture of safety simultaneously with reporting systems. If providers fear blame or repercussions, the likelihood of a successful reporting system is substantially reduced. So implementation efforts need to include cultural as well as practical dimensions of safety reporting.
Competing interests: None declared
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Competing Interests: None declared.