Patient Safety and Quality

Barriers impede efforts to use a region-wide hospital medication error reporting system

Medication-related errors harm 6 to 10 percent of hospitalized patients. Some States have passed laws requiring the reporting of medical errors, with penalties for delayed or incomplete reporting. However, to date, no clear-cut method of medical error reporting has been uniformly adopted with broad success. A new study of hospitals in the Pittsburgh region who participate in MEDMARX, a regional Web-enabled anonymous medication error reporting system, uncovered barriers to use of the regional system that need to be addressed in order to improve patient safety.

The researchers analyzed focus group remarks on medical error reporting by representatives from eight Pittsburgh hospitals (two urban, four community, one long-term care, and one pediatric). Participants identified four obstacles to reporting errors to the MEDMARX system and use of the MEDMARX quarterly report. First, few hospitals had sufficient dedicated staff for identification, verification, and reporting of errors. Efforts to promote reporting were compromised by other demands on staff time. Next, information systems in most hospitals were fragmented, leading to duplication of efforts and inefficiency. For example, most participating hospitals did not have computerized patient medical records or did not have the capacity to link pharmacy records to laboratory data to identify certain drug errors.

Participants also expressed concerns about benchmarking by hospital administrators and their reactions to increases in error reporting. For example, the process used to identify potential medication errors varied across hospitals, which could result in artificial differences in hospital-specific error rates. Finally, hospitals could generate internal error reports for analyses much faster than they received the quarterly MEDMARX reports. These last two issues had a negative impact on report use and dissemination. The study was supported by the Agency for Healthcare Research and Quality (HS11926).

More details are in "Perceived barriers in using a region-wide medication error reporting system," by Kim C. Coley, Pharm.D., Janice L. Pringle, Ph.D., Robert J. Weber, M.S. and others, in the March 2006 Journal of Patient Safety 2(1), pp. 39-44.

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