Reporting Medication Errors Improves Pharmacy Services

Medication error reporting, review, and information dissemination are essential tools for improving processes in pharmacy services. Why? Because when you know better, then you can do better.

Being the chair of an adverse drug event committee in the past has taught me that although your facility may seemingly have high numbers of medication error reports, it actually shows that your organization is being proactive in identifying areas where you can improve and ultimately prevent more serious events.

Voluntary error reporting has become the “gold standard” for most organizations/companies, but emphasis must be placed on the importance of reporting by the individual who identifies the error at the time it occurs. This can be done through an electronic or written format, but it should not be ignored while believing that “near misses are not important” or "I don’t have time to document.” Leadership must take an active role in encouraging and supporting staff to report any and all errors that are discovered.

The second and most important step, in my opinion, is the review of all reported errors. Designating an individual to perform a review daily of errors identifies system problems that can be changed immediately. Additionally, monthly or quarterly reporting can identify trends that could be related to specific medications, automation mix-ups, or order entry confusion. You may even identify specific staff members that require additional training or education.

Error reporting is not meant to be punitive, but to make individuals aware and more alert to processes and procedures. Otherwise, the same mistakes will continue to happen over and over again.

If your company or organization does not have a formal adverse drug event committee, then reports need to be reviewed in a leadership meeting of some sort. Utilizing a multidisciplinary committee to review medication errors that involve physician prescribing, nursing transcription/administration, and medication dispensing emphasizes to staff that improving the ways we provide patient care is important to the organization.

All information gathered must be communicated with the staff in a manner that supports and encourages team improvements. It is not necessary to pinpoint a specific error; rather, determine where in the process it occurred and why. This will benefit not only those directly involved, but also co-workers who will know what to look for in the future.