Defining and classifying medical error: lessons for patient safety reporting systems

Area of Science:

• Healthcare quality improvement
• Patient safety research
• Organizational learning in healthcare

Background:

• Effective reporting of safety-related events is crucial for healthcare providers.
• The impact of event definition and classification on hospital learning remains under-explored.

Purpose of the Study:

• To investigate how defining and classifying safety-related events influences organizational routines for information gathering, incentive allocation, and data analysis.
• To understand the relationship between event categorization and a hospital's capacity for learning from safety incidents.

Main Methods:

• Conducted semi-structured interviews with professional staff and administrators at a tertiary care teaching hospital and its pharmacy.
• Focused primarily on pharmacy staff, audio-recorded, transcribed, and qualitatively analyzed interview data on medication safety monitoring and reporting systems.

Main Results:

• The definition of an event can lead to under-reporting of safety incidents.
• Classification of medication errors influences perceived incentives for reporting.
• Event classification can either improve or hinder organizational routines for data analysis and learning.
• Internal learning routines within a pharmacy may decrease the flow of medication error data to the wider hospital.

Conclusions:

• Findings highlight practical and research questions regarding the influence of event definition and classification on reporting systems.
• Improved understanding of how hospitals define and classify safety experiences can enhance learning and patient safety.