Experience with Medication Error Reporting

Systems in an Irish Hospital

Tim Delaney, FPSIHead of Pharmacy

AMNCH Tallaght, Dublin 24, Ireland

First OECD Health Care Quality Indicators Seminar on Improving Patient Safety Data Systems. Farmleigh House, Dublin, June 29-30, 2006

Indicators - starting point for change

Medication Error Reports as Indicators

OECD Health Technical Papers No. 19 (2004), p.29

Drugs involved in harmful incidents

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9

Top Drugs involved in Reports

Per

cen

tag

e o

f R

epo

rts

Enoxaparin

Paclitaxel

Amiodarone

Insulin

Moxifloxacin

Zoledronic acid

Aspirin

Clopidogrel

Tetracaine

(Kirke C. AnalyzErr Pilot Study 2006)

Irish Experience: Errors by stage of the

Medication Use Process (all reports)

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Presc

ribing

Order

ing

Dispen

sing/

Deliver

y

Admini

strat

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Mon

itorin

gN/A

Per

cen

tag

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f R

epo

rts

(Kirke C. AnalyzErr Pilot Study 2006)

Stage involved in harmful incidents(Kirke C. AnalyzErr Pilot 2006)

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Presc

ribing

Order

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Dispen

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5 Principles for Creating an Environment for Safety

1. Culture: There should be a non-punitive culture for reporting healthcare errors that focuses on preventing and correcting systems failures and not on individual or organisation culpability.

2. Data Analysis: Information submitted to reporting systems must be comprehensively analysed to identify actions that would minimise the risk that reported events recur.

General Principles for Patient Safety Reporting Systems, (NCCMERP 2003)

5 Principles for Creating an Environment for Safety

3. Confidentiality. Confidentiality protections for patients,

healthcare professionals, and healthcare organizations

are essential to the ability of any reporting system to

learn about errors and effect their reduction.

4. Information Sharing. Reporting systems should

facilitate the sharing of patient safety information among

healthcare organizations and foster confidential

collaboration with other healthcare reporting systems

General Principles for Patient Safety Reporting Systems, (NCCMERP 2003)

5 Principles for Creating an Environment for Safety

5. Legal Status of Reporting System Information. • The absence of legal protection for information submitted

to patient safety reporting systems discourages the use of such systems, which reduces the opportunity to identify trends and implement corrective measures.

• Information developed in connection with reporting systems should be privileged for purposes of state judicial proceedings in civil matters, and for purposes of state administrative proceedings, including with respect to discovery, subpoenas, testimony, or any other form of disclosure

General Principles for Patient Safety Reporting Systems, (NCCMERP 2003)

Legal protection and reporting

• In Ireland, incident report and analysis may be protected under the Freedom of Information Act but are still discoverable in the event of civil litigation

• This is a significant deterrent to the production of RCA reports.

Factors to Consider when Comparing Reporting Rates

• Reporting Culture

• Differences in the types of reporting and detection system

• Differences in the patient populations served

• Definition of error

1. Culture

• Differences in culture among health

care organisations can lead to

significant differences in the level of

reporting of medication errors.

Culture - sense-making in a community of practice

Fellenz. M. (Trinity College Dublin / Irish Management Institute, 2006)

Drive out fear!

Great loss is associated with fear, when workers are afraid to ask a question of to take a position.

A secure worker will report faults and point to conditions that impair quality

W. Edwards Deming : “Out of the Crisis” (1986)

Staff Values (1998)

RespectCaringOpennessPartnership &

teamworkFairness & equity

Reporting Culture (2000) Blame Punishment Secrecy Adversity Cynicism Unfairness &

inequity

AMNCH – A culture of safety?

100%99%97%

83%

49%

0

20

40

60

80

100

120

140

160

Pharmacists Nurses Pharmacytechnicians

Doctors Dieticians

No

. R

epo

rts

(Oct

-Dec

200

4)

0%

20%

40%

60%

80%

100%

Cu

mu

lati

ve %

Rep

ort

s

Frequency Cumul %

Reporting culture varies between professions at AMNCH

2. Populations Served

• Differences in the patient populations served by various health care organisations can lead to significant differences in the number and severity of medication errors occurring among organisations.

3. Definition of error

• Differences in the definition of a

medication error among health care

organisations can lead to significant

differences in the reporting and

classification of medication errors.

Definition – what’s in a name?

Hierarchy of Medication Safety Incidents

N e a r M iss H a za rd o u s C o n d it ion

P o te n tia lA d ve rse D ru g E ve n t

(P A D E )

A d ve rse D ru g R e a c tion(A D R )

M e d ica tio n E rro r

A d ve rse D ru g E ve n t(A D E )

M e d ica tionS a fe ty

In c id e n t

Source: AMNCH Tallaght: Medication Safety Incident Reporting Policy DTC4/2002

OECD uses JCAHO operational definition

OECD Health Technical Papers No. 19 (2004), p.29

NCC MERP Definition “Any preventable event that may cause or lead to

inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labelling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

NCCMERP (1998)

4% of reported incidents involved patient harm

(AMNCH data 2004)

67 69

119

318 4 0 0 1

0

50

100

150

A B C D E F G H I

NCCMERP Category

Num

ber o

f Rep

orts

(Kirke C. AMNCH Data Oct-Dec 2004)

7% of reported incidents involved patient harm

(5 Irish Hospitals Pooled Data, 2006)

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100

A B C D E F G H I

NCC-MERP Category

Per

cen

tag

e o

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epo

rts

Cu

mu

lati

ve P

erce

nta

ge

Percentage ofReports

CumulativePercentage

(Kirke C. AnalyzErr Pilot Study 2006)

Issues with definitions

• OECD definition is equivalent to NCC MERP Categories G and I

• Covers only 2 of 5 NCC MERP sub-categories of errors causing harm

• Excludes a major harm category -errors where emergency intervention was needed to sustain life

4. Reporting Systems

• Differences in the types of reporting

and detection systems for medication

errors among health care organizations

can lead to significant differences in the

number of medication errors recorded

Medication Safety Incident Reports Received Monthly

Jan 2001 - December 2005

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Target Total Medication Safety Incidents Reported in Adult and Paediatric Services Six-Monthly Mean

Monthly Medication Safety Incident Reporting at AMNCH 2001-2005

AMNCH Tallaght Dispensary Errors 2004/2005

Errors detected in Pharmacy 2004 2,125Errors detected on Ward 81Errors reaching patient 41

Detection in Pharmacy per 100,000 items 709Detection in Ward per 100,000 items 27Not detected (given to patient) per 100,000 items 14

Errors detected in Pharmacy 2005 2,795Errors detected on Ward 77Errors reaching patient 21

Detection in Pharmacy per 100,000 items 1067Detection in Ward per 100,000 items 29Not detected (given to patient) per 100,000 items 8

Limitations of passive reporting

OECD Health Technical Papers No. 19 (2004), p.30

What is counted? Medication Error reporting at AMNCH Tallaght

2002-5

0100020003000400050006000700080009000

10000

2002 2003 2004 2005

Nu

mb

er o

f R

epo

rts

Dispensary errors

Medication Safety Incident Reports

Aseptic Unit Errors

Clinical pharmacist QA Interventions

What CIS sees Medication Error reporting at AMNCH Tallaght

2002-5

0100020003000400050006000700080009000

10000

2002 2003 2004 2005

Nu

mb

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f R

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Dispensary errors

Medication Safety Incident Reports

Aseptic Unit Errors

Clinical pharmacist QA Interventions

“ Mistakes are

the portals

of discovery.”James Joyce