RT Journal Article
SR Electronic
T1 Field Test Results of a New Ambulatory Care Medication Error and Adverse Drug Event Reporting System—MEADERS
JF The Annals of Family Medicine
JO Ann Fam Med
FD American Academy of Family Physicians
SP 517
OP 525
DO 10.1370/afm.1169
VO 8
IS 6
A1 John Hickner
A1 Atif Zafar
A1 Grace M. Kuo
A1 Lyle J. Fagnan
A1 Samuel N. Forjuoh
A1 Lyndee M. Knox
A1 John T. Lynch
A1 Brian Kelly Stevens
A1 Wilson D. Pace
A1 Benjamin N. Hamlin
A1 Hilary Scherer
A1 Brenda L. Hudson
A1 Caitlin Carroll Oppenheimer
A1 William M. Tierney
YR 2010
UL http://www.annfammed.org/content/8/6/517.abstract
AB PURPOSE In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)—an easy-to-use, Web-based reporting system designed for busy office practices. METHODS We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports. RESULTS A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting “has increased the fear of repercussion in the practice.” Time pressure was the main barrier to reporting. CONCLUSIONS It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.