SALT LAKE CITY — It's a bad thing when a medication error occurs in a nursing facility. It's a good thing when that error is reported and the result is improved procedures. But it's a common thing for a wrong medication or dose to go unreported because the facility doesn't have a readily available reporting system or form.
That's the key message from results of a novel study that set out to identify barriers to medication error reporting in nursing homes.
“Efforts to improve medication error reporting frequency should focus on organizational rather than on individual-level interventions,” Dr. Steven M. Handler suggested at the annual symposium of the American Medical Directors Association.
Medication errors, as defined by the Centers for Medicare and Medicaid Services under F-tag 332, include preparation or administration of drugs not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards. Reporting of such errors is important so facilities can understand the causes of errors, make responsible parties aware of correctable problems, and improve patient care, Dr. Handler said.
In 2005, Dr. Handler of the division of geriatric medicine at the University of Pittsburgh and his associates created a survey by first asking physicians, pharmacists, nurses, and other advanced practitioners, “From the perspective of your profession, what are the reasons for not reporting medication errors in the nursing home?”
The researchers also asked participants to say whether the obstacles to error reporting were “organizational” (involving the process of reporting medication errors) or “individual” (involving the preferences, abilities, or characteristics of people responsible for reporting errors).
From these preliminary answers, the team created a 20-item survey and administered it to 145 of the health professionals at four nursing homes in Pennsylvania.
The respondents used a five-point scale to score factors in terms of their likelihood of posing a barrier (“very likely” to “very unlikely”) and their potential to be corrected (“not modifiable” to “very modifiable”). The survey's response rate was 68%, Dr. Handler said.
Four of the top five barriers that the respondents considered to be the most modifiable were organizational processes: a lack of a readily available medication-reporting system or forms, a lack of information on how to spot a medication error, a lack of feedback to the reporter or to the rest of the facility on reported medication errors, and a time-consuming error-reporting system or form.
Dr. Handler called the lack of feedback “particularly important. If the expectation is that all medication errors should be reported, then staff should have an equal expectation that all reported medication errors will be reviewed and analyzed, and that some form of action will be taken to prevent the same or similar events from occurring in the future.”
Only one individual obstacle made the list of five most-modifiable barriers to error reporting: Ranked fourth was lack of knowledge of which medication errors should be reported.
“The study results provide a broad-based perspective of the barriers to medication error reporting in the nursing home setting,” Dr. Handler said. “To the best of our knowledge, this represents the first study that's focused on this outcome in the nursing home setting.”
He acknowledged certain limitations of the study, which was published last year (J. Am. Med. Dir. Assoc. 2007;8:568–74). These include the fact that the sample, for convenience, involved only a few nursing homes. In addition, the study excluded the perspective of medication technicians, since the state of Pennsylvania doesn't allow them to administer medications.
The study was supported in part by an AMDA/Pfizer Quality Improvement Award, by a Merck/American Federation for Aging Research Junior Investigator Award in Geriatric Clinical Pharmacology, and by grants from the National Institutes of Health.
'Efforts to improve medication error reporting frequency should focus on organizational … interventions.' DR. HANDLER