Nonpunitive medication error reporting: 3-year findings from one hospital's Primum Non Nocere initiative

To identify underlying practices and attitudes on medication error occurrences and reporting practices.

In response to a hospital-wide quality improvement initiative, a task force was formed to facilitate a nonpunitive culture toward reporting medication errors. To identify underlying practices and attitudes on medication errors and medication error reporting, a baseline survey was conducted. Based on findings, an initiative that included modifications to clinical and administrative processes was developed and implemented.

A pre/post initiative questionnaire to measure staff practices and attitudes on medication error reporting was developed and administered. Findings from the presurvey were used to craft the Nonpunitive Patient Safety Policy and its implementation plan. Pre-post comparative analysis was performed following a baseline-postimplementation design.

Conceptually, a medication error is qualified by its outcome severity. Medication errors with more serious outcomes are more likely to be reported than those with less serious ones. Staff perception that medication error reporting carries the risks of disciplinary action was identified as a primary barrier to the likelihood of reporting.

Evaluation of the initiative suggests that a multicomponent approach facilitates positive movement in the direction of a nonpunitive culture toward reporting medication errors.