Hicks R, Cousins DD, Santell JP, Cowley EP, McMeekin J, Becker S, Camp S; Academy for Health Services Research and Health Policy. Meeting.

Abstr Acad Health Serv Res Health Policy Meet. 2002; 19: 20.

Practitioner and Product Experience, U S Pharmacopeia, 12601 Twinbrook Parkway, Rockville, MD 20852-1790; Tel: (301) 816-8338; Fax: (301) 816-8532; E-mail: RH@usp.org

RESEARCH OBJECTIVE: Medication errors are common in America's complex system of health care and represent shortcomings in the medication use process as was clearly identified by The Institute of Medicine's (IOM) report in November 1999. The IOM report went so far as to identify the elements needed to bridge the chasm between the healthcare a person now receives and what they should receive. Voluntary, national confidential reporting systems have many roles in patient safety. These systems provide a standardized taxonomy for event reporting and aggregate analysis. These systems strive to detect system weaknesses before the occurrence of harm. They provide rich information within an individual health care organization for internal quality improvement efforts and they can serve collaborative and comparative efforts between health care organizations. One such reporting program is MedMARx, an Internet-accessible, anonymous, medication error database. Hospitals using MedMARx are able to collect, analyze, and compare their own medication error data with other hospitals on a national level. In this way, hospitals and other health care organizations can better assess error-prone areas within their own medication-use processes, identify opportunities for systems improvements, and apply risk prevention strategies by taking steps to error proof their hospital based on the unfortunate experiences of others. STUDY DESIGN: A team of methodological and clinical staff conducted cross tab analysis of medication error reports using the Error Severity Index (developed by NCC MERP), Error type, Level of Care as result of error, Node, Cause(s) of error, Contributing factor(s), Product involved, Action(s) taken, and Patient outcomes. POPULATION STUDIED: All released records submitted through MedMARx subscribers over a 3-year period, January 1, 1999 - December 31, 2001. PRINCIPAL FINDINGS: Nearly 150,000 records from over 400 health care facilities were reviewed with 92% of the records being categorized as errors that actually occurred, and 63% of the records being categorized as errors that reached the patient. About 3% of the records indicated patient harm. Products most commonly associated with harm were: Insulin, Heparin, Warfarin, Morphine. The top types of errors, causes of errors, contributing factors, actions taken, and patient outcome findings will be presented. CONCLUSIONS: The recurring and consistent trends observed from the MedMARx data should represent a clear call to action, and underscore the need to change the medication use process, the perceptions of error reporting, the culture fostered by administration and staff, and the facility's willingness and readiness to adopt solutions. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: In July 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implemented new standards directly focused on patient safety. These standards call for organizations to prioritize performance improvement initiatives. The willingness of participants in a national medication error reporting program to share information, even in the absence of federal legislation to protect such information, attests to the effectiveness of a model that supports anonymous reporting. A national database that functions at a local level offers considerable prospects for healthcare stakeholders - the information can be used by individual hospitals and by national organizations to develop quality indicators, and to identify policies and procedures that work. PRIMARY FUNDING SOURCE: Foundations, US Pharmacopeia

Publication Types:

• Meeting Abstracts

Keywords:

• Americas
• Cooperative Behavior
• Delivery of Health Care
• Evaluation Studies
• Hospitals
• Humans
• Joint Commission on Accreditation of Healthcare Organizations
• Medication Errors
• Medication Systems
• Medication Systems, Hospital
• Pharmaceutical Preparations
• Pharmacopoeias
• Records as Topic
• Risk Management
• Safety Management
• Total Quality Management
• drug therapy
• economics
• organization & administration
• therapy
• trends
• hsrmtgs

Other ID:

• GWHSR0002540

UI: 102274216

From Meeting Abstracts