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ISMP survey shows weaknesses persist in hospital systems for error detection, reporting and analysis

From the November 15, 2000 issue

Error detection, reporting, and analysis are at the very heart of patient safety. Yet, based upon 417 reader responses to the recent ISMP Survey on Medication Error Detection, Reporting, and Analysis, it's clear that we need to pay greater attention to the processes involved and the environment in which these functions take place.

By far, spontaneous reports from staff are the most common method (97%) used to identify errors, according to our survey. Alternative methods of error detection, that may provide a greater yield of information through more streamlined processes, have not been widely adopted. Only 19% of respondents use a telephone hotline or other method to simplify error reporting. Sixty percent of respondents said they reviewed medication records (MARs) or patients' charts to uncover errors, but only 32% reviewed drug or laboratory "triggers" or "markers" that may signal an error. Only 17% used medical record external cause codes or "E codes" to identify adverse drug events. Although access to valuable error-related data may be easy to obtain, it may not actually used to improve medication safety. For example, more than a quarter of respondents (29%) said they had not collected and used information about pharmacy interventions to correct prescribing errors. As a result, about half of them said these intercepted errors are unlikely to be reported. More importantly, they are most likely to be repeated! Also, respondents felt that only 40% of dispensing errors and 46% of transcription errors were likely to be reported. Instead, respondents said it is more likely for staff to report errors that actually reach the patient and cause harm. Yet surprisingly, only 76% of respondents had full confidence that even these harmful errors would be reported in their facility. Potentially hazardous situations that could lead to an error were the least likely to be reported, which demonstrates how reactive, rather than proactive, healthcare continues to be today.

Sadly, as we attempt to understand and embrace a non-punitive culture of safety in regards to medical error reporting, professionals continue to practice under the shadow of blame and punishment. The most prevalent actions taken against healthcare providers involved in serious or potentially serious errors include counseling and individual remedial education. While these actions may not seem outwardly punitive, these tacit forms of reprimand lead to underreporting of errors. Respondents consistently reported that nurses have been punished for serious or potentially serious errors more frequently and harshly than other disciplines. Almost half of the respondents reported the frequent use of verbal reprimands. Over a third of respondents reported that nurses receive written reprimands or other forms of punishment, such as discussion of the error in a performance evaluation. Organizations continue to discipline nurses involved in errors by assigning points or demerits (18%), suspending or terminating employment (14%), and/or reporting the error to the licensing board (13%). In comparison, respondents reported less frequent and severe punishment for physician errors. For example, 12% of respondents reported that serious errors were included in physician performance appraisals or reappointment, yet such action occurred almost twice as often (21%) for pharmacists, and almost three times as often (35%) for nurses. However, physicians were about three times more likely than pharmacists to appear before a peer review committee, and almost twice as likely as nurses. A culture of blame and fear perpetuated through the use of disciplinary action may explain why 39% of respondents offer an anonymous reporting system within their organizations.

The survey results also showed an inconsistent application of punishment and reward between various healthcare provider groups. For example, while respondents reported that nurses received more frequent and harsh punishment for serious errors, nurses also were more frequently rewarded for reporting serious errors (11%) and provided with psychological counseling (17%) after an error. While respondents reported that physicians received the least punishment for serious errors, only 2% of respondents reported that physicians were rewarded for reporting an error and only 6% reported that they were provided with psychological counseling.

The true incidence of medication errors varies, depending heavily on the rigor with which the events are identified and the comfort level of the staff that report them. Thus, a high "error rate" may suggest either unsafe medication practices or an organizational culture that promotes error reporting. Conversely, a low "error rate" may suggest successful error prevention strategies or a punitive culture that inhibits error reporting. Focus on maintaining a low "error rate" promotes an unproductive cycle of underreporting errors. While ISMP and others have repeatedly discouraged "error rate" calculations due to significant unreliability of the collected data, 84% of respondents have embraced the practice of calculating and comparing "error rates."

Finally, 89% of respondents claim to have some form of an organization-wide, formal committee responsible for improving the medication use process. It is encouraging that almost two thirds (61%) of the committees regularly review errors occurring in other organizations and take proactive measures to prevent similar errors within their own facilities. Unfortunately, the remaining 39% of respondent committees are likely spending more time "fighting fires" instead of preventing them. Using external errors as a lens to examine systems in your own organization can help promote a non-punitive environment and clearer understanding of the system-based causes of errors. Staff will be more comfortable discussing a serious external error rather than one that has occurred within their own organization. Once blame is no longer an issue, defensive posturing and other obstacles to effective discussion will not be present. In this environment, staff can easily begin to identify possible system-based causes of the error, determine the likelihood of a similar error in their own facility, and suggest solutions. As improvements are made, organizational enthusiasm will build for identifying, reporting, and analyzing errors that are actually occurring. Put simply, discussion about external medication errors, near misses or hazardous conditions promotes a more effective analysis of internal system-based causes of medication errors. A table listing complete survey results appears below.


1. Is there an organization-wide, formal committee responsible for improving the medication use process? 89%
2. Does the committee regularly review errors occurring in other organizations and take proactive measures to prevent similar errors? 61%
3. How are medication errors involving patients identified and reported? (check all that apply)
     a. Self-initiated reports by staff (e.g., incident report, electronic entry into computer) 97%
     b. Self-initiated, but anonymous, reports by staff 39%
     c. Self-initiated verbal reports by staff to a hot-line telephone number 19%
     d. Automated/manual review of markers or triggers for targeted drug orders and laboratory tests 32%
     e. Chart review and/or MAR review 60%
     f. Data collection at critical checkpoints (pharmacy interventions, etc.) 71%
     g. E codes or other indicators 17%

4. How likely is it for practitioners to report the following errors or potential errors? 1 = not likely; 5 = very likely
Types of Errors 1% 2% 3% 4% 5%
a. Errors that reach the patient and cause harm 2% 2% 4% 15% 76%
b. Errors that reach the patient but cause no harm 4% 11% 27% 27% 30%
c. Drug preparation and dispensing errors that are intercepted before they reach the patient 14% 26% 23% 22% 14%
d. Prescribing errors that are intercepted before reaching the patient 26% 23% 22% 12% 14%
e. Transcription errors that are detected before reaching the patient 21% 25% 26% 15% 11%
f. Potentially hazardous situations that could lead to an error 20% 25% 27% 16% 8%


5. Which departments receive notification of all medication error-related reports, regardless of the practitioners/departments involved?
a. Medicine (or other relevant medical departments) 46%
b. Nursing 64%
c. Pharmacy 83%
d. Quality Improvement 71%
e. Risk Management 80%
f. Nursing Administration 60%
g. Hospital Administration 51%


6. Please indicate which of the following actions have been taken in your organization in the past two years, even if infrequently, when practitioners have been involved in a serious or potentially serious error or have committed numerous errors.
Actions Physician Pharmacist Nurse Others
(e.g. technician, etc.)
a. Rewarded for reporting error 2% 6% 11% 2%
b. Amnesty granted if error reported 10% 14% 17% 7%
c. Asked to participate in a root cause analysis 53% 66% 74% 31%
d. Staff counseled 25% 66% 80% 33%
e. Remedial education 12% 35% 63% 20%
f. Verbal reprimand 8% 27% 46% 15%
g. Required to appear before a "peer review" committee 13% 5% 8% 2%
h. Written reprimand in personnel file 3% 13% 35% 75%
i. Assign demerits/points with cumulative consequences 1% 5% 18% 2%
j. Disciplinary action 3% 10% 34% 7%
k. Included in performance appraisal or reappointment 12% 21% 35% 8%
l. Suspension 1% 3% 14% 3%
m. Termination 1% 3% 16% 2%
n. Reported to licensing board 4% 5% 13% 2%
o. Provided with psychological support/counseling 6% 11% 17% 4%
p. No action taken 0% 16% 13% 7%

7. Are error rates, derived from the number of error reports, calculated, reported, and used for comparison? 84%


  MD RPh RN LPN Risk
Professional designation of respondent: 2% 76% 11% 4% 5%  
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