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Experience with Medication Error Reporting Systems in an Irish Hospital Tim Delaney, FPSI Head 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

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experience with medication error reporting systems in an irish hospital

Experience with Medication Error Reporting Systems in an Irish Hospital

Tim Delaney, FPSI

Head 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

medication error reports as indicators
Medication Error Reports as Indicators

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

drugs involved in harmful incidents
Drugs involved in harmful incidents

(Kirke C. AnalyzErr Pilot Study 2006)

irish experience errors by stage of the medication use process all reports
Irish Experience:Errors by stage of the Medication Use Process (all reports)

(Kirke C. AnalyzErr Pilot Study 2006)

5 principles for creating an environment for safety
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 safety8
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 safety9
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.

Legal protection and reporting
factors to consider when comparing reporting rates
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
1. Culture
  • Differences in cultureamong health care organisations can lead to significant differences in the level of reporting of medication errors.
culture sense making in a community of practice
Culture - sense-making in a community of practice

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

drive out fear
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

AMNCH – A culture of safety?

Staff Values (1998)

Reporting

Culture (2000)

  • Respect
  • Caring
  • Openness
  • Partnership & teamwork
  • Fairness & equity
  • Blame
  • Punishment
  • Secrecy
  • Adversity
  • Cynicism
  • Unfairness & inequity
reporting culture varies between professions at amnch
Reporting culture varies between professions at AMNCH

160

100%

100%

140

97%

99%

80%

83%

120

100

60%

Cumulative % Reports

No. Reports (Oct-Dec 2004)

49%

80

40%

60

40

20%

20

0

0%

Pharmacists

Nurses

Pharmacy

Doctors

Dieticians

technicians

Frequency

Cumul %

2 populations served
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
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
Definition – what’s in a name?

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

oecd uses jcaho operational definition
OECD uses JCAHO operational definition

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

ncc merp definition
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
4% of reported incidents involved patient harm(AMNCH data 2004)

(Kirke C. AMNCH Data Oct-Dec 2004)

7 of reported incidents involved patient harm 5 irish hospitals pooled data 2006
7% of reported incidents involved patient harm(5 Irish Hospitals Pooled Data, 2006)

(Kirke C. AnalyzErr Pilot Study 2006)

issues with definitions
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
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
amnch tallaght dispensary errors 2004 2005

Errors detected in Pharmacy 2005

2,795

Errors detected on Ward

77

Errors reaching patient

21

Detection in Pharmacy per 100,000 items

1067

Detection in Ward per 100,000 items

29

Not detected (given to patient) per 100,000 items

8

Errors detected in Pharmacy 2004

2,125

Errors detected on Ward

81

Errors reaching patient

41

Detection in Pharmacy per 100,000 items

709

Detection in Ward per 100,000 items

27

Not detected (given to patient) per 100,000 items

14

AMNCH Tallaght Dispensary Errors 2004/2005
limitations of passive reporting
Limitations of passive reporting

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

slide33
“ Mistakes are

the portals

of discovery.”

James Joyce