Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level...

Area of Science:

• Healthcare Management
• Patient Safety
• Clinical Pharmacy

Background:

• Medication errors pose a significant risk in intensive care units.
• Effective interventions are needed to improve medication safety and reporting rates.

Purpose of the Study:

• To analyze the impact of cultural and system-level interventions on medication error reporting, errors with harm, and safety attitudes.
• To evaluate the effectiveness of a multi-faceted approach to enhance medication safety in an ICU setting.

Main Methods:

• Seven overlapping interventions were implemented over 2.5 years, including performance metric tracking, didactic curricula, and system changes like computerized physician order entry.
• Statistical process control analyzed medication error and harm rates, with annual Safety Attitudes Questionnaire (SAQ) responses collected.

Main Results:

• Medication error reporting increased by 25% (p<0.09), while errors resulting in harm decreased by 71% (p<0.01).
• The SAQ demonstrated improvements in all 13 medication safety items, with five reaching statistical significance (p<0.05).

Conclusions:

• A transparent and positive unit-level safety culture significantly improves medication safety.
• System-level interventions are crucial for translating safety culture into improved patient outcomes, and may be ineffective alone.