Mechanism of Action: Does it matter?
April 15, 2019
Corrective Actions to Reduce Medication Errors
April 29, 2019

Are We Underreporting?

According to a July 2016 Pharmacy Times article by Alan Polnariev, PharmD, MS, CGP entitled Overcoming Obstacles to Medication Error Reporting (, as of 2013 between 210,000 and 440,000 deaths occurred as a result of medication errors. As alarming as those figures are, “there may be as many as 100 errors that go unreported or undetected.” As a result, it becomes imperative to determine why incidents may go unreported.

Hartnell N, et al. in their 2012 BMJ article, cite research that suggests that “medication error reporting could be improved if the process of reporting errors were made easier and staff was adequately educated about reporting and received timely feedback about the results from the reports submitted.” Their research was based on the findings of a focus groups that included physicians, pharmacists, and nurses from 4 community hospitals. They compiled a list citing what they conclude to be the most commonly cited barriers to medication error reporting. These include

  1. Extra time required in reporting
  2. Cumbersome report forms
  3. Hesitancy about “telling” on someone
  4. Perceived severity of the error

In an effort to address these issues, the researchers formulated recommendations that should be considered. The most obvious was simplification of the process of medication error reporting as a means of improving compliance. If the reporting system itself is too cumbersome, not user friendly and takes an excessive amount of time, this tends to  compromise compliance. Reporting systems can be beneficial but begin to lose their effectiveness the more complex they become.

The second recommendation involved providing front-line staff with feedback. Those reporting the events tend to be positively reinforced when senior management reports the outcomes of a reported event. Conversely, “many participants voiced frustration that they did not receive feedback about error reports that had been submitted.”  Consequently, we can conclude that providing feedback to front-line staff is a critical component of an effective medication errors program.

The third recommendation was to ensure that all front-line staff and management are adequately trained regarding the reporting system. All members should feel comfortable with not only how the system works but understand why reporting is essential. “Education is an important feature because skeptics may not be completely persuaded that reporting errors improves patient safety.”

The researchers concluded that “Reporting should be made as easy as possible (forms should be accessible and straightforward), people should receive timely feedback about reports submitted, and people should receive up-to-date education about all aspects of the medication error reporting process at their hospitals.

A good reporting system should serve to increase reporting while identifying areas for improvement. As errors are identified and corrective measures implemented, the error rate should decrease over time in the targeted area. However, because errors will always occur, a good reporting system will continuously identify other areas to target and the process repeats itself.

Error rates that are too high suggest a good reporting system but a failure to follow up with implementation of corrective actions. Error rates that are too low tend to be indicative of an inefficient reporting system. A system that is unable to identify other areas for improvement, is suggestive of a system that needs to be reassessed.





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