Article Figures & Data
Tables
Network, Practice No. Physicians No. Midlevel Clinicians No. Support Staff No. Ownership Location EMR CCPC = Connecticut Center for Primary Care; CenTexNet = Central Texas Primary Care Research Network; CHC = community health center; EMR = electronic medical record; FQHC = Federally Qualified Health Center; LANet = Los Angeles Network; ORPRN = Oregon Rural Practice-based Research Network. ORPRN 1 5 4 38 Hospital, not for profit Rural No 2 4 4 25 Physician Rural Yes 3 3 4 16 Hospital, not for profit Rural Yes 4 4 0 9 Hospital, public Rural Yes 5 3 2 18 Physician Rural No CCPC 1 2 1 12 Physician Suburban No 2 6 3 21 Physician Urban No 3 2 2 16 Physician Suburban No 4 1 0 3 Physician Suburban No 5 2 1 8 Physician Suburban No 6 5 1 20 Physician Suburban No 7 1 1 5 Physician Suburban No 8 5 2 20 Physician Urban No 9 1 1 6 Physician Small town No LANet 1 8 7 37 FQHC Urban No 2 6 4 31 FQHC Suburban No 3 5 4 33 FQHC Urban No 4 1 1 13 FQHC Urban No 5 1 2 4 CHC Urban No CenTexNet 1 5 0 11 Hospital, not for profit Rural Yes 2 20 0 48 Hospital, not for profit Urban Yes 3 8 0 18 Hospital, not for profit Urban Yes 4 4 0 10 Hospital, not for profit Rural Yes 5 10 2 21 Hospital, not for profit Urban Yes Job Title CCPC No. (%) ORPRN No. (%) CenTexNet No. (%) LANeta No. (%) Total No. (%) CCPC = Connecticut Center for Primary Care; CenTexNet = Central Texas Primary Care Research Network; LANet = Los Angeles Network; ORPRN = Oregon Rural Practice-based Research Network. a In addition, 2 pharmacists and 4 pharmacy technicians from LANet participated. Physician 25 20 47 18 110 (50) Nurse 1 15 0 0 16 (7) Medical assistant 0 24 0 2 26 (12) Office clerk 0 7 0 0 7 (3) Office manager 10 5 0 0 15 (7) Physician assistant/nurse practitioner 11 14 2 13 46 (21) Total 47 (21) 85 (39) 49 (22) 39 (18) 220 (100) Type of Medication Percentage of Medication Event Reports Note: One percent or less: allergy; dermatology; diagnostic agents; ear, nose, and throat (not allergy or infection); eye; poisoning/drug dependence; genito-urinary; obstetrics-gynecology; not known. Cardiovascular 30 Central nervous system 17 Endocrine 12 Infectious diseases 11 Pain/pyrexia 8 Hematology 7 Gastrointestinal 3 Respiratory 3 Immunization 2 Musculoskeletal 2 Nutrition/vitamins/minerals 2 Type of Error Percentage of Errors OTC=over the counter. Note: Some reports included more than 1 error. Ordering medications 28 Dose prescribed is wrong 13 Drug prescribed is wrong 5 Failure to order needed medication 4 Wrong patient name on prescription 4 Contraindicated medication prescribed 2 Prescription telephoned to wrong pharmacy <1 Implementing orders 24 Drug label is incorrect 8 Dose dispensed is incorrect 7 Drug dispensed is incorrect 5 Medication is not dispensed 3 Failure to continue long-term medication 1 Receiving medications 20 Patient failed to take medication correctly 18 Patient continued medication after stop order 1.5 Different clinicians mixed up medications <1 Sample or OTC medication incorrectly supplied <1 Documenting 24 Medical record not up to date 23 Home medication list not up to date 1 Monitoring 4 Total 100 Contributing Factor Percentage of Errors and Events Notes: For 304 reports, the reporters did not select any contributing factors. Less than 2%: computer error, fax problem, sound-alike drug names, abbreviation misunderstood. Written communication problem 30 Knowledge deficit 22 Transcription error 14 Office procedure not followed 13 Verbal communication problem 11 Verbal order incorrect 7 Handwriting illegible 7 Look-alike drug names 4 Calculation error 4 Type of Harm Errors and Events No. (%) No harm 351 (69.2) Physical only 43 (8.5) Emotional only 7 (1.4) Physical and emotional 7 (1.4) Unknown 67 (13.2) Missing data 32 (6.3) Category Percentage of Participants MEADERS = Medication Error and Adverse Drug Event Reporting System. Note: A total of 164 of 220 participants provided feedback, for a survey response rate of 75%. Reported at least 1 event 57 Understood what should be reported Understood 82 Somewhat understood 16 Accessing MEADERS Little or no difficulty 96 Great difficulty 3 Could not access system 1 Using MEADERS (agreed or strongly agreed) “It is easy to use.” 90 Effect of reporting on the user (agreed or strongly agreed) “It allows me to be candid when reporting errors.” 79 “It encourages me to learn from my mistakes and the mistakes of others.” 64 “It increased my own awareness of how errors affect patient care.” 61 “It has helped me to improve patient care at my practice.” 41 “It has led to changes in how we practice medicine.” 25 “It has increased the fear of repercussion in the practice.” 36 “It takes too much time to submit a report.” 26 The study had affected their work personally 26 MEADERS would be used more often if: “There were a greater awareness of the system’s benefits.” 50 “I had more time or opportunity to access the system.” 50 MEADERS = Medication Error and Adverse Drug Event Reporting System. Positive comments “I am more cognizant of potential errors and adverse events and more vigilant about not repeating them.” “I am more aware of medication errors and the importance of careful med review/prescribing practices.” “I am more aware of all the different types of medication errors that go on in day to day practice.” “It made me more aware of the number of errors and made me more careful when doing my job.” “I’m more cautious in giving shots and med samples.” Negative comments “I do not have a computer at my work station. To write down the events and input them later was time consuming and cumbersome.” “It was difficult to determine which category to report issues in. It was also difficult to remember to do it at the end of the day.” “I do not think the average primary care doctor has time to do this!” “Only a small amount of errors got logged due to the time required.”
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.
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