Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit

Department of Health Management and Policy, School of Public Health, University of Michigan, 1113 Olivia Avenue, Ann Arbor, MI 48104, USA.
BMJ quality & safety (Impact Factor: 3.28). 06/2011; 20(11):914-22. DOI: 10.1136/bmjqs.2010.047233
Source: PubMed

ABSTRACT This study analyses patterns in reporting rates of medication errors, rates of medication errors with harm, and responses to the Safety Attitudes Questionnaire (SAQ), all in the context of four cultural and three system-level interventions for medication safety in an intensive care unit.
Over a period of 2.5 years (May 2007 to November 2009), seven overlapping interventions to improve medication safety and reporting were implemented: a poster tracking 'days since last medication error resulting in harm', a continuous slideshow showing performance metrics in the staff lounge, multiple didactic curricula, unit-wide emails summarising medication errors, computerised physician order entry, introduction of unit-based pharmacy technicians for medication delivery, and patient safety report form streamlining. The reporting rate of medication errors and errors with harm were analysed over time using statistical process control. SAQ responses were collected annually.
Subsequent to the interventions, the reporting rate of medication errors increased 25%, from an average of 3.16 to 3.95 per 10,000 doses dispensed (p<0.09), while the rate of medication errors resulting in harm decreased 71%, from an average of 0.56 to 0.16 per 10,000 doses dispensed (p<0.01). The SAQ showed improvement in all 13 survey items related to medication safety, five of which were significant (p<0.05).
Actively developing a transparent and positive safety culture at the unit level can improve medication safety. System-level mechanisms to promote medication safety are likely important factors that enable safety culture to translate into better outcomes, but may be independently ineffective in the face of poor safety culture.


Available from: Matthew F Niedner, May 30, 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: To determine if standardised chart review applied to records of patients discussed at a paediatric intensive care unit (PICU) morbidity and mortality conference (MMC) yields additional or different information regarding safety event occurrence and characteristics.
    BMJ quality & safety 07/2014; 23(11). DOI:10.1136/bmjqs-2014-003000 · 3.28 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: /st>Incident reporting is an important component of health care quality improvement. The objective of this investigation was to evaluate the effectiveness of an emergency department (ED) peer review process in promoting incident reporting. /st>An observational, interrupted time-series analysis of health care provider (HCP) incident reporting to the ED during a 30-month study period prior to and following the peer review process implementation and a survey-based assessment of physician perceptions of the peer review process' educational value and its effectiveness in identifying errors. /st>Large, urban, academic ED. and INTERVENTIONS: /st>HCPs were invited to participate in a standardized, non-punitive, non-anonymous peer review process that involved analysis and structured discussion of incident reports submitted to ED physician leadership. /st>Monthly frequency of incident reporting by HCPs and physician perceptions of the peer review process. /st>HCPs submitted 314 incident reports to the ED over the study period. Following the intervention, frequency of reporting by HCPs within the hospital increased over time. The frequencies of self-reporting, reporting by other ED practitioners and reporting by non-ED practitioners within the hospital increased compared with a control group of outside HCPs (P = 0.0019, P = 0.0025 and P < 0.0001). Physicians perceived the peer review process to be educational and highly effective in identifying errors. /st>The implementation of a non-punitive peer review process that provides timely feedback and is perceived as being valuable for error identification and education can lead to increased incident reporting by HCPs.
    International Journal for Quality in Health Care 04/2014; DOI:10.1093/intqhc/mzu045 · 1.58 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective: To systematically examine the research literature to identify which interventions reduce medication errors in pediatric intensive care units. Data Sources: Databases were searched from inception to April 2014. Study Selection and Data Extraction: Studies were included if they involved the conduct of an intervention with the intent of reducing medication errors. Data Synthesis: In all, 34 relevant articles were identified. Apart from 1 study, all involved single-arm, before-and-after designs without a comparative, concurrent control group. A total of 6 types of interventions were utilized: computerized physician order entry (CPOE), intravenous systems (ISs), modes of education (MEs), protocols and guidelines (PGs), pharmacist involvement (PI), and support systems for clinical decision making (SSCDs). Statistically significant reductions in medication errors were achieved in 7/8 studies for CPOE, 2/5 studies for ISs, 9/11 studies for MEs, 1/2 studies for PGs, 2/3 studies for PI, and 3/5 studies for SSCDs. The test for subgroup differences showed that there was no statistically significant difference among the 6 subgroups of interventions, chi(2)(5) = 1.88, P = 0.87. The following risk ratio results for meta-analysis were obtained: CPOE: 0.47 (95% Cl = 0.28, 0.79); IS: 0.37 (95% Cl = 0.19, 0.73); ME: 0.36 (95% Cl = 0.22, 0.58); PG: 0.82 (95% Cl = 0.21, 3.25); PI: 0.39 (95% Cl = 0.10, 1.51), and SSCD: 0.49 (95% Cl = 0.23, 1.03). Conclusions: Available evidence suggests some aspects of CPOE with decision support, ME, and IS may help in reducing medication errors. Good quality, prospective, observational studies are needed for institutions to determine the most effective interventions.
    Annals of Pharmacotherapy 07/2014; 48(10). DOI:10.1177/1060028014543795 · 2.92 Impact Factor