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.

  • [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; · 1.79 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To explore nurses' and physicians' attitudes and perceptions relevant to safety culture and to elicit strategies to promote safety culture in an intensive care unit. A strong safety culture is essential to ensure patient safety in the intensive care unit. This case study adopted a mixed method design. The Safety Attitude Questionnaire (SAQ-ICU version), assessing the safety climate through six domains, was completed by nurses and physicians (n = 42) in an academic intensive care unit. Twenty semi-structured interviews and document analyses were conducted as well. Interviews were analysed using a framework analysis method. Mean scores across the six domains ranged from 52.3 to 72.4 on a 100-point scale. Further analysis indicated that there were statistically significant differences between physicians' and nurses' attitudes toward teamwork (mean scores: 64.5/100 vs. 52.6/100, d = 1.15, t = 3.69, P < 0.001) and job satisfaction (mean scores: 78.2/100 vs. 57.7/100, d = 1.5, t = 4.8, P < 0.001). Interviews revealed several safety challenges including underreporting, failure to learn from errors, lack of speaking up, low job satisfaction among nurses and ineffective nurse-physician communication. The results indicate that all the domains need improvements. However, further attention should be devoted to error reporting and analysis, communication and teamwork among professional groups, and nurses' job satisfaction. Nurse managers can contribute to promoting a safety culture by encouraging staff to report errors, fostering learning from errors and addressing inter-professional communication problems.
    Journal of Nursing Management 08/2013; · 1.14 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To analyze the impact of a multidisciplinary and decentralized safety committee in the pediatric management unit, and the joint implementation of a computing network application for reporting medication errors, monitoring the follow-up of the errors, and an analysis of the improvements introduced. An observational, descriptive, cross-sectional, pre-post intervention study was performed. An analysis was made of medication errors reported to the central safety committee in the twelve months prior to introduction, and those reported to the decentralized safety committee in the management unit in the nine months after implementation, using the computer application, and the strategies generated by the analysis of reported errors. Number of reported errors/10,000 days of stay, number of reported errors with harm per 10,000 days of stay, types of error, categories based on severity, stage of the process, and groups involved in the notification of medication errors. Reported medication errors increased 4.6 -fold, from7.6 notifications of medication errors per 10,000 days of stay in the pre-intervention period to 36 in the post-intervention, rate ratio 0.21 (95% CI; 0.11-0.39) (P<.001). The medication errors with harm or requiring monitoring reported per 10,000 days of stay, was virtually unchanged from one period to the other ratio rate 0,77 (95% IC; 0,31-1,91) (P>.05). The notification of potential errors or errors without harm per 10,000 days of stay increased 17.4-fold (rate ratio 0.005., 95% CI; 0.001-0.026, P<.001). The increase in medication errors notified in the post-intervention period is a reflection of an increase in the motivation of health professionals to report errors through this new method.
    Anales de Pediatría 02/2014; · 0.87 Impact Factor


Available from
Jun 4, 2014