Patient Safety/Quality

Researchers examine factors that affect voluntary reporting of medication errors

An estimated 1 of every 131 outpatient deaths can be attributed to medication errors. The United States Pharmacopeia (USP), in cooperation with the Institute for Safe Medication Practices (ISMP), monitors medication errors through the Medication Errors Reporting (MER) program, which can be used by practitioners in any practice setting to voluntarily report medication errors.

A recent study supported by the Agency for Healthcare Research and Quality (HS13891) surveyed community pharmacists in Vermont to assess their awareness and use of MER. The study found that although 62 percent of the pharmacists surveyed had heard of MER, only 21 percent had ever reported a medication error.

Without error reporting, no mechanism exists to analyze, understand, and eliminate medication errors, according to Amanda G. Kennedy, Pharm.D., B.C.P.S., and Benjamin Littenberg, M.D., of the University of Vermont College of Medicine. They conducted telephone interviews with one community pharmacist from each operating community pharmacy in Vermont during 2002 and 2003. A total of 113 pharmacists responded to the survey.

Significantly more pharmacists employed by independent pharmacies had submitted an error report, compared with pharmacists from other pharmacy types (chain, supermarket, or mass merchandiser). The primary reason cited by pharmacists for not submitting reports directly to USP MER was not lack of time. Instead, they were concerned that reports had to be submitted to corporate superiors or headquarters (37 percent), and they did not know if the reports were forwarded to USP MER.

The researchers suggest that pharmacy managers or corporate offices adopt policies of sending copies of all pharmacist reports to the national program for pooled analyses. If physicians' offices are aware of a medication error, they also should have the management support to complete and submit reports.

See "Medication error reporting by community pharmacists in Vermont," by Drs. Kennedy and Littenberg, in the July 2004 Journal of the American Pharmacists Association 44, pp. 434-438.

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