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Identifying modifiable barriers to medication error reporting in the nursing home setting
Steven M Handler1, Subashan Perera, Ellen F Olshansky
1Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA. handlersm@upmc.edu
Journal of the American Medical Directors Association
|November 14, 2007
Summary
Barriers to medication error reporting in nursing homes are primarily organizational. Improving reporting requires addressing systemic issues like lack of reporting systems and feedback, not individual performance.
Area of Science:
- Healthcare quality improvement
- Medication safety in long-term care
- Health services research
Background:
- Medication errors are a significant concern in nursing homes, impacting patient safety and quality of care.
- Effective medication error reporting systems are crucial for identifying and mitigating risks.
- Understanding modifiable barriers is essential for enhancing reporting accuracy and frequency.
Purpose of the Study:
- To identify organizational and individual modifiable barriers to medication error reporting among healthcare professionals in nursing homes.
- To inform targeted interventions aimed at improving medication error reporting rates.
Main Methods:
- Utilized nominal group technique sessions to brainstorm potential barriers.
- Developed and administered a 20-item cross-sectional mailed survey to nursing home professionals (physicians, pharmacists, advanced practitioners, nurses).
- Employed Likert scales to assess the likelihood and modifiability of identified barriers.
Main Results:
- A total of 104 (67.5%) professionals responded to the survey.
- 14 out of 20 survey items (70%) were identified as immediate action factors.
- Nine of these factors (64%) were organizational, with the top three being lack of reporting systems/forms, insufficient reporting information, and absence of feedback on reported errors.
Conclusions:
- The study highlights that organizational-level factors present the most significant and modifiable barriers to medication error reporting in nursing homes.
- Interventions should prioritize systemic changes within nursing home facilities to improve medication error reporting.
- Focusing on organizational improvements is more effective than individual-level interventions for enhancing reporting frequency.
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