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Medication error reporting: a survey of nursing staff
J A Antonow1, A B Smith, M P Silver
1HealthInsight Salt Lake City, Utah, USA.
Journal of Nursing Care Quality
|September 29, 2000
Summary
Anonymous surveys reveal significant underreporting of medication errors (MEs). Most MEs are preventable, but reporting rates vary by error type and stage, highlighting needs for improved hospital medication safety systems.
Area of Science:
- Patient Safety
- Healthcare Quality Improvement
- Medication Management
Background:
- Medication errors (MEs) pose a significant risk in healthcare settings.
- Underreporting of MEs hinders effective quality improvement initiatives.
- Understanding factors influencing reporting is crucial for enhancing patient safety.
Purpose of the Study:
- To report findings from a medication error (ME) survey.
- To estimate the extent of ME underreporting by comparing survey data with incident reports (IRs).
- To identify factors associated with the reporting of MEs.
Main Methods:
- A survey was administered to registered nurses in a pediatric hospital's infant unit.
- Nurses described recent medication errors, classifying them by timing, nature, prevention, and patient injury.
- Survey data on MEs were compared with written incident reports (IRs) over a 6-month period.
Main Results:
- The survey achieved a 93.5% response rate, with 72 nurses reporting 177 errors.
- Approximately 40.3% of nurses observed an ME in the preceding week.
- Only about 30% of identified MEs were documented in IRs, with administration errors more likely to be reported than ordering errors, especially if not prevented from reaching the patient.
Conclusions:
- Anonymous ME surveys effectively augment traditional incident reporting systems.
- Identifying errors by stage and type provides valuable data for monitoring and improving hospital medication systems.
- Targeted interventions can address underreporting and enhance overall medication safety.
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