Improving the Reporting of Medication Errors: BACKGROUND
In October 2006, several nurses, pharmacists and providers commented that the medication error-reporting process at the Veterans Affairs-New York Harbor Healthcare System (VA-NYHHS) was lengthy and cumbersome and did not promote the reporting of all medication close calls and adverse events. The staff’s concerns were validated by the medication error-reporting data.
In fiscal year 2006 (from October 1, 2005, to September 30, 2006), the NYHHS reported a total of 61 medication errors. The reporting range included two acute-care facilities, one nursing facility, and several outpatient clinics and residential treatment programs. A breakdown of the total number of reported medication errors appears in Figures 1 through 4. The number of medication errors (n = 61) for fiscal year 2006 appeared to be grossly underreported, given that the total number of outpatient prescriptions was 142,203 and the number of inpatient unit doses dispensed was 151,730,484 that same year. canadian pharmacy online
Figure 1 Comparison of the total number of medication errors reported in the first three quarters of fiscal year 2007 and fiscal year 2006 at the VA-New York Harbor Healthcare System.
AN INTERDISCIPLINARY APPROACH
TO REPORTING ERRORS
In an effort to streamline the medication error-reporting process and to increase reporting of close calls and adverse events, an interdisciplinary team consisting of nurses, pharmacists, and employees from the Quality Management (QM) Office was assembled. The group first tackled the reporting vehicle, known as the Incident Report (VA Form 10-2633). Even though staff members of the unit were accustomed to using that form to report all types of incidents, they felt that using the Medication Incident Evaluation Report instead to report medication errors would be quicker and easier. At that time, only the Medication Error Committee was using the form as duplicate documentation to categorize medication errors that were reported to Quality Management via the Medication Incident Evaluation Report (Figure 5). buy antibiotics in canada
Figure 2 Comparison of the total number of medication errors reported in the first three quarters of fiscal year 2007 and fiscal year 2006 at Campus A.
The interdisciplinary committee reviewed the existing reporting tool with the idea of simplifying the document and making it more user-friendly. After much discussion, the team edited the Medication Error Evaluation Report so that incidental questions were removed, a section for post-incident evaluation by a physician was added, and the bottom portion of the form was grayed-out (to be completed by the Medication Error Committee). silagra 100
Figure 3 Comparison of the total number of medication errors reported in the first three quarters of fiscal year 2007 and fiscal year 2006 at Campus B.
After the revisions were made, the committee agreed that the form was an acceptable and comprehensive tool with which to report medication errors. After that decision was made, the staff was instructed informally by their service chiefs, and formally by a Senior Leadership broadcast message, to use the Medication Error Evaluation Report to list all close calls and adverse events.
Figure 4 Comparison of the total number of medication errors reported in the first three quarters of fiscal year 2007 and fiscal year 2006 at Campus C.
TRAINING PHARMACY RESIDENTS AND PHARMACY STUDENTS
In addition to improving the reporting tool, the pharmacy service formally trained all pharmacy residents and students in Internal Medicine to report medication close calls and adverse events using the newly edited form. Like medical residents, pharmacy residents are on the front line of patient care and see firsthand the errors that occur. The Director of the VA Harbor Pharmacy Residency Program revised the Resident Portfolio, a tool that captures the resident’s workload, to include reporting sections on medication errors and adverse events. With support and guidance from the Clinical Pharmacy Specialists and preceptors of Internal Medicine rotations, pharmacy residents and pharmacy students started to report medication errors to the Quality Management staff on a regular basis. buy tadacip
Figure 5 Medication Incident Evaluation Report. MUE = medication use evaluation; VANYHHS = Veterans Affairs-New York Harbor Healthcare System.
