Translating research into practice: voluntary reporting of medication errors in critical access hospitals.
BACKGROUND
Low service volume, insufficient information technology, and limited human resources are barriers to learning about and correcting system failures in small rural hospitals.


OBJECTIVE
This paper describes the implementation of and initial findings from a voluntary medication error reporting program developed by the Nebraska Center for Rural Health Research (NCRHR) to overcome these barriers in 6 Nebraska critical access hospitals (CAHs).


METHODS
Participating Nebraska CAHs mailed copies of medication error reports to the NCRHR monthly for entry into a database. Quarterly summaries enabled each CAH to compare its reports by severity, type, phase of the medication use process, contributing factors, and causes to those of its peers and MEDMARX, a national medication error reporting program. Workshops emphasized learning from the reported errors by identifying system sources of variation in medication use and initiating change to achieve best practices.


RESULTS
Similar to MEDMARX, 99% of medication errors reported by 6 Nebraska CAHs were not harmful, reported errors most often originated in the administration phase, and the most common error type was omission. The CAHs reported significantly smaller proportions of "near miss" errors and errors originating in the prescribing phase than in MEDMARX.


CONCLUSIONS
By collaborating with CAHs, an academic medical center, and a national reporting program, the NCRHR is translating the Institute of Medicine's recommendation for voluntary error reporting into practices that allow CAHs to learn about and improve their medication use systems. However, limited presence of pharmacists in CAHs is a barrier to implementing double checks and learning from system failures in the medication use system.
Jones
Katherine J
KJ
Nebraska Center for Rural Health Research, University of Nebraska Medical Center, Omaha, NE 68198-4350, USA. kjonesj@unmc.edu
Cochran
Gary
G
Hicks
Rodney W
RW
Mueller
Keith J
KJ
D016907:Adverse Drug Reaction Reporting Systems / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000191:economics*; D006751:Hospital Information Systems / Q000458:organization & administration; D006780:Hospitals, Rural / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D009329:Nebraska / Q000453:epidemiology; D010348:Patient Care Team / Q000458:organization & administration; D012308:Risk Management / Q000458:organization & administration*; D012423:Rural Health; D011795:Surveys and Questionnaires; D013689:Telephone; D035141:Voluntary Programs