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Every error a treasure: improving medication use with a nonpunitive reporting system.

David F Lehmann1, Nancy Page, Karen Kirschman

  • 1Department of Medicine, State University of New York Upstate Medical Universtiy, Syracuse, New York, USA. lehmannd@upstate.edu

Joint Commission Journal on Quality and Patient Safety
|August 23, 2007
PubMed
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Implementing a nonpunitive reporting system significantly increased medical event reports. This change facilitated quality improvements in medication safety by encouraging staff to report errors without fear of punishment.

Area of Science:

  • Healthcare Quality Improvement
  • Patient Safety
  • Medication Error Reporting

Background:

  • Fear of reprisal and time constraints discourage medical event reporting.
  • Previous punitive systems led to underreporting and missed safety improvement opportunities.
  • Upstate Medical University Hospital developed a nonpunitive system to reduce drug harm.

Purpose of the Study:

  • To evaluate the impact of a nonpunitive medication event reporting policy.
  • To assess the effect on the number of reported medication events.
  • To determine if quality improvements in medication safety were achieved.

Main Methods:

  • A nonpunitive medication event reporting policy was implemented in October 2000.
  • Data from 18 months before and after the policy change were compared.

Related Experiment Videos

  • The study analyzed the number of monthly medication event reports.

    • Main Results:

    • The average number of monthly reports increased from 19 to 102 after the policy change (p < .001).
    • The nonpunitive system successfully encouraged increased reporting of medication events.

    Conclusions:

    • A nonpunitive reporting system is effective in increasing medication event reports.
    • Systematic analysis of increased reports leads to substantive quality improvements in medication safety.