Article Figures & Data
Tables
Additional Files
Supplemental Table & Figure
Supplemental Table 1. Data Fields in the MEADERS Event Reporting Form; Supplemental Figure 1. Number of event reports submitted per week per network.
Files in this Data Supplement:
- Supplemental data: Table & Figure - PDF file, 2 pages, 299 KB
The Article in Brief
Field Test Results of a New Ambulatory Care Medication Error and Adverse Drug Event Reporting System�MEADERS
John Hickner , and colleagues
Background Event reporting, a safety improvement method in which workers report problems that may be solved by changing systems or policies, has been an effective tool in hospitals, but hasn't been tested in the primary care setting. This study evaluated an easy-to-use, Web-based office system for reporting medication errors (errors in prescribing, dispensing or using medications) and adverse drug events (injuries due to medication use).
What This Study Found A Web-based system for reporting medication errors and adverse drug events appears to be feasible in the medical office setting. There was little difficulty and minimal time demand on the part of study participants. During the course of the 10-week field test, participants identified errors nearly equally distributed throughout the medication management spectrum in four major categories: ordering, dispensing, receiving, and documenting. At least 43 percent of participants reported one or more medication event during the study period, a high participation rate for event reporting. The most frequent contributors to medication errors and adverse drug events were communication problems (41 percent) and knowledge deficits (22 percent). Many participants indicated the reporting process positively affected the safety culture of their practices by increasing awareness of medication errors and adverse drug events and prompting changes in office routines for managing medications; however, 36 percent of participants also felt the event reporting increased the fear of repercussion in the practice. Participants identified time pressure as the main barrier to reporting.
Implications
- It is feasible to deploy a Web-based medication event reporting system that clinicians and staff can understand and use in busy primary care practices.
- A culture of safety has not yet taken hold in all primary care practices; some study participants feared possible reprisal from reporting errors. This must change before event reporting can be a catalyst for improvement in ambulatory care.