Alan Polnariev, PharmD, MS, CGP
Alan Polnariev, PharmD, MS, is a board-certified pharmacist committed to improving patient safety by championing pharmaceutical outcomes research and policy. He received his PharmD from Long Island University and a master’s degree in Patient Safety and Risk Management from the University of Florida, where he currently serves as a clinical assistant instructor for several courses in the school’s Master of Science program. Dr. Polnariev has provided consulting services for various pharmacy organizations, including the National Association of Boards of Pharmacy and Institute for Safe Medication Practices.
According to a 2012 study, preventable medical errors cost the US economy as much as $1 trillion annually in “lost human potential and contributions.”3 The study’s researchers used quality-adjusted life years to develop what they called a “more complete accounting of the economic impact when someone dies from a preventable error.”3
Still, their figures may represent only the tip of the iceberg. For every reported medication error that causes injury to a patient, there may be as many as 100 errors that go unreported or undetected.4
Results from other research indicate the frequency of medication error reporting could be improved if the process of reporting errors were made easier and staff was adequately educated about reporting and received timely feedback about the results from the reports submitted. To reach this conclusion, the investigators conducted in-depth interviews and focus groups with physicians, pharmacists, and nurses from 4 community hospitals and compiled a list of the most commonly cited barriers to medication error reporting:5
- Extra time required in reporting
- Cumbersome report forms
- Hesitancy about “telling” on someone
- Perceived severity of the error
The first was reducing reporter burden to simplify the process of reporting errors as a means to increase reporter compliance. The general consensus of the study participants was incident reporting systems were “not user friendly, and as a result, took too long to complete.”
The second recommendation was improving the channels of communication between senior management and front-line staff, as “many participants voiced frustration that they did not receive feedback about error reports that had been submitted.” Participants commonly expressed the desire to receive recognizable feedback from administration.
The third recommendation was increasing awareness and education to help front-line staff better understand the process of reporting (how to report, why to report, and how reports were being used). Education is an important feature because skeptics may not be completely persuaded that reporting errors improves patient safety.
All 3 of those interventions may help staff members feel more confident about reporting medication errors and contributing to efforts to advance patient safety.
“Reporting should be made as easy as possible (forms should be accessible and straightforward), people should receive timely feedback about reports submitted, and people should receive up-to-date education about all aspects of the medication error reporting process at their hospitals,” the researchers concluded.5
The simple yet effective approaches they offered are an excellent foundation to not only improve medication error reporting, but also markedly improve the frequency of reported medication errors. Still, broader approaches are warranted. Identifying the hurdles health care professionals face on a regular basis is an important first step to improve error reporting, but there’s plenty more work to be done.
Nobody has all of the answers to the problem, but arriving at the solution involves brainstorming sessions and the combined efforts of interdisciplinary health care teams. Most approaches to address this problem will likely fall into 1 of 3 categories: organizational culture, system improvements, and staff education.
Organizational culture focuses on the behaviors, stigmas, and attitudes toward patient safety processes in a health care setting. How senior management responds to reported errors from front-line staff is one example. Another is a structured process to prioritize and thoroughly investigate medication errors and patient safety concerns.
System improvements involve communication channels for sharing information (eg, error reporting systems) and their accessibility and ease of use in allowing reporters to enter the details of a medication error efficiently and effectively. Providing a highly visible and open means of communicating information between senior management and front-line staff is an essential component of the error reporting cycle.
Finally, staff education would encompass topics like which incidents should be reported; differentiating terms like medication error, adverse drug event, and near miss; and how to properly report an incident.
Medication errors are as a dire a concern today as they were in 1999. The call to action is loud and clear, with hundreds of thousands of lives lost and hundreds of billions of dollars spent annually. The health care industry can’t afford to stay idle any longer.
In order to prevent medication errors, we must modify how we view them and learn from our past mistakes. Understanding how to overcome obstacles to error reporting is a great way to start.
1. Kohn LT, Corrigan JM, Donaldson MS; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999.
2. James JT. A new, evidence-based estimate of patient harm associated with hospital care. J Patient Saf. 2013;9(3):122-128.
3. Andel C, et al. The economics of health care quality and medical errors. J Health Care Finance. 2012;39(1).
4. Duthie E, Favreau B, Ruperto A, et al. Advances in Patient Safety: From Research to Implementation. Rockville, MD: Agency for Healthcare Research and Quality, 2005.
5. Hartnell N, et al. Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study. BMJ Qual Saf. 2012;21:361-368.