Field Test Results of a New Ambulatory Care Medication Error and Adverse Drug Event Reporting System--MEADERS

Abstract

PURPOSE In this study, we developed and fi eld tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy offi ce practices. METHODSWe conducted a 10-week fi eld test of MEADERS in which 220 physicians and offi ce staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with offi ce managers and lead physicians, and (2) distributions of characteristics of the medication event reports.RESULTS A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication err ors and adverse drug events were communication problems (41%) and knowledge defi cits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in offi ce medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting. CONCLUSIONS It is feasible for primary care clinicians and offi ce staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.

Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes

“…1 Others have demonstrated that errorand event-reporting systems can be implemented in primary care; however, these rarely focus on near misses or the coordination of near-miss reports with quality improvement (QI). [2][3][4][5][6][7][8][9] Barriers to reporting events include the additional workload burden, concern over punitive action, lack of confidence that positive change will result, and psychological barriers to admitting an error. 10 -14 Anonymous reporting systems may increase the number of error reports and reduce concerns about punitive actions but might reduce the detail of the events.…”

Patient safety in primary health care: a systematic review

“…There was a balance in the yearly distribution of the articles' publication: four in 2007 9,10,11,12 , six in 2008 13,14,15,16,17,18 , three in 2009 19,20,21 , ten in 2010 22,23,24,25,26,27,28,29,30,31 , six in 2011 32,33,34,35,36,37 and four in 2012 38,39,40,41 (Table 2).…”

“…Some studies used interviews to obtain data, either with physicians 25,33,39 or with physicians and other health professionals 24 . Questionnaires were also used by some authors to extract data, and were answered by physicians 22,40 , physicians and other health professionals 10,16,28,34 , or patients and family members 26,27 . Other studies used a combination of methods for data sources: incident reporting systems, direct observation, and focus groups 35 ; incident reporting systems, direct observation, and interviews 11 ; direct observation with audio recording 29 ; direct observation and expert consensus 36 ; incident reporting systems, patient file review, and interviews 41 ; incident reporting systems and patient file review 21 ; incident reporting systems, interviews, and questionnaires 30 ; expert consensus, questionnaires for patients, and focus groups 31 ; incident reporting systems, patient file review, and questionnaires 41 (Table 2).…”

“…The study population consisted of physicians and other health professionals 9,10,13,14,15,16,19,20,22,24,25,28,30,32,33,34,35,36,39,40 , patients and families 26 , and health professionals and patients and families 11,21,23,27,29,31,41 , while in some studies the study population was not described in complete detail 17,22,38 (Table 2).…”

“…Eight studies 13,14,15,17,21,27,32,34 aimed to identify the types and severity of incidents in primary care and their contributing factors; 19 studies 9,11,16,18,19,20,22,23,24,25,26,29,30,33,35,37,39,40 aimed to indicate solutions to make primary care safer for the patient; and six studies 12,28,31,36,38,41 aimed to evaluate the tools for improving patient safety in primary care.…”