Statement Advocating Against the Use of Medication Error Rates Based on Voluntarily Reported Errors to Compare Health Care Organizations
| The National Coordinating Council for Medication Error Reporting and Prevention believes there is no acceptable incidence rate for medication errors. To demonstrate a consistent medication error rate internally or amongst organizations a clearly defined numerator, denominator, and standardized data collection system would be required to comprehensively detect both. Due to the reasons stated below, it is impracticable to develop a quantitative measurement (i.e., error rate). Use of medication error rates to compare health care organizations or changes over time is of no value. |
The use of medication error rates to compare health care organizations or measure changes over time is not recommended for the following reasons:
- Differences in culture among health care organizations can lead to significant differences in the reporting of medication errors. Organizations that encourage medication error reporting by providing incentives and resources to report within a non-punitive, continuous quality improvement arena will likely report more medication errors than organizations that wish to conceal errors and punish individuals who are involved in or report errors.
- Differences in the definition of a medication error among health care organizations can lead to significant differences in the reporting and classification of medication errors. For example, some organizations may only consider actual errors that reach the patient as errors. Other organizations also will include potential errors and errors that do not reach the patient. The latter organizations will likely collect more medication errors, and information from reports of potential errors can sometimes be more useful in prevention efforts than reports of actual errors.
- Differences in the patient populations served by various health care organizations can lead to significant differences in the number and severity of medication errors occurring among organizations. For example, tertiary care hospitals generally may serve more severely ill patients than rehabilitation hospitals. In addition, the intensity of drug therapies, the types of drugs used, and the methods of drug distribution may be substantially different in these environments, thereby leading to differences in number and types of errors.
- Differences in the type(s) of reporting and detection systems for medication errors among health care organizations can lead to significant differences in the number of medication errors recorded. Passive reporting systems, relying upon voluntary reports from staff, are known to result in far fewer medication error reports than active surveillance systems are able to detect. Also, the number of error reports can be significantly different, depending on the type of active surveillance system (e.g., direct observation versus retrospective review of medical records versus computer-based data gathering from electronic medical records and order entry systems).
The goal of every health care organization should be to continually improve systems to prevent harm to patients due to medication errors.
- Health care organizations should make deliberate, routine efforts to assess their culture of safety, promote a Just Culture, and identify barriers to voluntary reporting from staff.
- Health care organizations should encourage reporting of actual and potential medication errors by patients, family members, and patient advocates.
- Health care organizations should monitor actual and potential medication errors that occur within their organization and investigate the root cause of errors with the goal of identifying ways to improve the medication use system to prevent future errors and potential patient harm.
The goal of medication error reporting programs is to provide information that allows an organization to identify weaknesses in its medication use system and to apply lessons learned to improve the system. The sheer number of error reports is less important than the quality of the information collected in the reports, the health care organization's analysis of the information, and the strength of its corrective actions to improve the system to prevent harm to patients.
Furthermore, health care organizations need to adopt multiple approaches to risk identification and analysis including:
- conducting proactive risk assessments and Failure Mode Effects Analyses (FMEA),
- direct observation of processes,
- root cause analysis (RCA) (e.g., do more errors occur when short-staffed, during holidays, during night shift, with new employees, etc),
- trigger assessments,
- retrospective chart reviews,
- focus groups with frontline staff,
- review of technology data (e.g., smart pumps, barcode medication administration, alert overrides, pharmacy interventions), and
- ongoing review of external sources of information.
The combination of proactive risk identification along with effective response to medication error reporting will yield much more meaningful change within an organization as opposed to trending of medication error rates over time and comparing rates across organizations.
Emphasis should be on implementation of effective risk reduction strategies based on a thoughtful analysis of details involving the reported errors and not solely on counting how often a particular error is voluntary reported.
Actions/Decisions are those of the Council as a whole and may not reflect the views/positions of individual member organizations.