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Voluntary medication error reporting program in a Japanese national university hospital
Hiroyuki Furukawa1, Hisashi Bunko, Fumito Tsuchiya
1Department of Pharmacy, Kanazawa University Hospital, Kanazawa, Japan. sambista-knz@umin.ac.jp
Background:
In Japan, as in other countries, medical accidents arising from human error can seriously damage public confidence in medical services, as well as being intrinsically undesirable.
Objective:
Errors voluntarily reported by the healthcare practitioners in our institution (Kanazawa University Hospital) were considered to assess the contributory factors by using the accumulated error database in the hospital information system.
Methods:
Medical errors in our institution during the period from July 1, 2000, to June 30, 2002, were counted using the error reporting system database and were classified.
Results:
The number of errors reported during the investigation period was 1378, of which 78% were reported by nursing staff. Medication errors involving administration of injectable or oral drugs to inpatients, dispensing, and prescription accounted for about 50% of that number. Among dispensing errors, 53% were detected by patients or their families and 36% by nurses.
Conclusions:
The best method of error prevention is to learn from previous errors. For this purpose, the error reporting program is effective. In patient safety management, it is important to take into account the potential risks of future errors, as well as to capture information about errors that have already happened. For safety management, adoption of appropriate information technology (e.g., implementation of a prescription order entry system) is effective in reducing medication errors. However, it is important to note that serious errors can also arise in computer-based systems.
Insights
Learning from medical errors is crucial for patient safety. An error reporting program helps identify risks and improve healthcare, especially in medication administration.
Area of Science:
- Medical error analysis
- Patient safety research
- Healthcare quality improvement
Background:
- Medical accidents from human error erode public trust and are undesirable.
- Effective patient safety management requires learning from past incidents.
Purpose of the Study:
- To assess contributory factors of medical errors using a voluntary reporting system.
- To analyze medical error data accumulated in a hospital information system.
Main Methods:
- Collected and classified medical errors reported between July 2000 and June 2002.
- Utilized the hospital's error reporting system database for data analysis.
Main Results:
- 1378 errors were reported, with 78% from nursing staff.
- Medication errors (administration, dispensing, prescription) comprised ~50% of total errors.
- Patients/families detected 53% of dispensing errors; nurses detected 36%.
Conclusions:
- Error reporting programs are effective for learning from past mistakes and improving patient safety.
- Integrating information technology, like electronic prescribing, can reduce medication errors.
- Vigilance is needed as computer-based systems can also introduce serious errors.