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Related Experiment Videos

Medication error reporting in long term care.

Steven M Handler1, David A Nace, Stephanie A Studenski

  • 1Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA. steven.handler@verizon.net

The American Journal of Geriatric Pharmacotherapy
|November 25, 2004
PubMed
Summary
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Medication errors in long-term care facilities are frequently unreported due to reporting processes and fear of disciplinary action. Improving reporting requires broader monitoring and a supportive environment.

Area of Science:

  • Healthcare quality and safety
  • Geriatric pharmacy practice
  • Long-term care administration

Background:

  • Medication errors are a significant cause of medical errors in long-term care (LTC).
  • Most medication errors in LTC facilities go unreported, hindering improvement efforts.
  • Understanding current reporting systems is crucial for developing better ones.

Purpose of the Study:

  • To describe medication use and error reporting processes in a single LTC facility.
  • To characterize nursing staff's knowledge, attitudes, and beliefs regarding medication errors.
  • To identify factors influencing medication error reporting in LTC.

Main Methods:

  • Observations and semi-structured interviews to define processes.
  • Review and summarization of medication error reports over 21 months.

Related Experiment Videos

  • Survey of nursing staff on knowledge, attitudes, and beliefs about medication errors.

    • Main Results:

    • The medication use process involves prescribing, documenting, dispensing, administering, and monitoring.
    • An average of 4.7 medication error reports were submitted monthly.
    • Staff perceived that half of errors were communicated informally; 85% believed disciplinary action followed errors.

    Conclusions:

    • LTC medication error policies are linked to low reporting, limited error source perspectives, and fear of punishment.
    • Future research should focus on better error identification and interventions.
    • Developing an institutional culture of participation over punishment is essential.