Assessing Causation in a Medical Malpractice Case
April 1, 2019
Mechanism of Action: Does it matter?
April 15, 2019

Most hospitals practice continuous quality improvement and therefore have some type of medication error program in place. In many instances, we find that hospitals have an automated system for tracking medication errors. Many however, may lack the necessary finances and therefore, have chosen to track their medication errors manually. While other smaller hospitals, bed size <25, usually find that they can manage the 1 to 2 medication errors they see each month using a manual reporting system. Either means is acceptable as long as the Joint Commission approves, of course.

The ultimate goal of tracking is always to reduce medication errors. This is best achieved when all healthcare providers that are involved with providing medications have a vested interest in the process. We find that if nurses, pharmacists, physicians, etc. are actively engaged, they are more likely to report an error as it occurs. If automated systems are forced on the participants, there is a tendency to participate in the process only because it is required.

In our surveys, we find that many respondents do not feel that their current medication error tracking program is adequately efficient either because 1) the automated system does not provide the customization needed, 2) it fails to provide the necessary query or reporting capability, 3) it takes too long for data entry or 4) it is simply not user-friendly enough. What this means ultimately, is that even though these systems are better than no system, the ability to analyze the data and effectively reduce medication errors is compromised. So there is certainly room for improvement.

In addition, it is important that the participants “by in” to the process. If they are dissatisfied with the system, this makes it less likely that they will be active participants. We suggest that decision makers ensure that the medication error programs that they are using, are not only capturing the data that needs to be monitored but are also acceptable to the participants who are providing the information that ends up in these very programs. It is also essential that participants are made aware of the results. This ultimately reinforces the effectiveness of the program and should hopefully encourage continued participation.

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