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Reducing medication errors in hospitals: a peer review organization collaboration.

M P Silver1, J A Antonow

  • 1HealthInsight, Salt Lake City, UT 84107, USA. msilver@healthinsight.org

The Joint Commission Journal on Quality Improvement
|June 7, 2000
PubMed
Summary

This Utah hospital project significantly reduced medication errors by over 26% through collaborative system changes. The initiative also improved error detection and reporting, enhancing patient safety.

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Area of Science:

  • Health Services Research
  • Patient Safety Science
  • Medication Safety

Background:

  • Published data on adverse drug events (ADEs) in hospitalized patients prompted a voluntary medication error reduction project.
  • Initiated in 1997 by a Medicare peer review organization for Utah hospitals.

Purpose of the Study:

  • To implement and evaluate a collaborative project aimed at reducing medication errors in Utah hospitals.
  • To assess the impact of medication system changes on patient safety.

Main Methods:

  • Hospitals formed teams to evaluate and modify medication processes using ergonomic principles and error studies.
  • Anonymous surveys of clinical staff assessed medication errors before and after project implementation.

Main Results:

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  • Thirteen Utah acute care hospitals participated (1997-1998).
  • Analysis of 560 survey responses showed a 26.9% decrease in overall medication error frequency.
  • Error detection and prevention increased by 12.5%, and formal reporting of errors increased by 24.1%.

Conclusions:

  • The project demonstrated a community interest in proactive, collaborative patient safety initiatives.
  • Implemented changes were substantive and sustainable, suggesting a reduction in medication errors.
  • Improved capacity for medication error detection and prevention was observed in participating organizations.