ISMP Medication Safety Alert

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ISMP Subscriber Survey on Medication Error Detection, Reporting, and Analysis

From the August 23, 2000 issue

To identify the most common processes used to detect, report, and analyze medication errors, and treat practitioners who make serious or frequent errors, we hope that you will participate in the following survey and mail or fax the results to ISMP (215 914 1492) by September 29, 2000. We plan to report the findings and comment on these issues in an October 2000 edition of the newsletter. Thank you!

1. Is there an organization-wide, formal committee responsible for improving the medication use process?
2. Does the committee regularly review errors occurring in other organizations and take proactive measures to prevent similar errors?
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)
     b. Self-initiated, but anonymous, reports by staff
     c. Self-initiated verbal reports by staff to a hot-line telephone number
     d. Automated/manual review of markers or triggers for targeted drug orders and laboratory tests
     e. Chart review and/or MAR review
     f. Data collection at critical checkpoints (pharmacy interventions, etc.)
     g. E codes or other indicators
     h. Other (please describe):

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
b. Errors that reach the patient but cause no harm
c. Drug preparation and dispensing errors that are intercepted before they reach the patient
d. Prescribing errors that are intercepted before reaching the patient
e. Transcription errors that are detected before reaching the patient
f. Potentially hazardous situations that could lead to an error
5. Which departments receive notification of all medication error-related reports, regardless of the practitioners/departments involved?
  Yes No
a. Medicine (or other relevant medical departments)
b. Nursing
c. Pharmacy
d. Quality Improvement
e. Risk Management
f. Nursing Administration
g. Hospital Administration
h. Other (specify):
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
b. Amnesty granted if error reported
c. Asked to participate in a root cause analysis
d. Staff counseled
e. Remedial education
f. Verbal reprimand
g. Required to appear before a "peer review" committee
h. Written reprimand in personnel file
i. Assign demerits/points with cumulative consequences
j. Disciplinary action
k. Included in performance appraisal or reappointment
l. Suspension
m. Termination
n. Reported to licensing board
o. Provided with psychological support/counseling
p. No action taken
q. Other (specify)

7. Are error rates, derived from the number of error reports, calculated, reported, and used for comparison?
  MD RPh RN LPN Risk
Professional designation of respondent:

Thank you for participating! Please fax responses to ISMP at 215-914-1492 by September 29, 2000.

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