Medication error reporting in long term care.
BACKGROUND
Medication errors are common causes of medical error in the long-term care (LTC) setting. Despite their frequency and potential clinical impact, most medication errors in LTC facilities remain unreported. Before better reporting systems can be developed to reduce clinically significant medication errors, it is necessary to understand how current medication error reporting systems function.


OBJECTIVE
This study describes the medication use and medication error reporting processes, and characterizes the knowledge, attitudes, and beliefs about medication errors of the nursing staff at a single LTC facility.


METHODS
Three methods were used to characterize the medication use and medication error reporting processes and the nursing staff's perceptions about such errors. First, key elements and basic processes were defined through observation and semi-structured interviews. Second, medication error reports were reviewed and summarized over a 21-month period. Third, nursing facility staff were surveyed about their knowledge, attitudes, and beliefs concerning medication errors.


RESULTS
The medication use process in the LTC setting is similar to that employed in the acute care setting, consisting of 5 steps: prescribing, documenting, dispensing, administering, and monitoring. In the facility studied, an average of 4.7 medication error reports were submitted per month. Staff felt that half of all medication errors were identified and communicated informally through change-of-shift reports rather than through medication error reports. Most staff (85%) believed that disciplinary action was taken against the person who committed an error.


CONCLUSIONS
The medication error policies and processes of the LTC facility studied were associated with a low frequency of formal reporting, a narrow perspective on the sources of error, and concerns about disciplinary action. Research is needed to better identify errors, develop interventions that broaden the monitoring perspective to include all health care professionals, reduce the work of reporting, standardize the information collected, and create an institutional atmosphere of participation rather than punishment.
Handler
Steven M
SM
Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA. steven.handler@verizon.net
Nace
David A
DA
Studenski
Stephanie A
SA
Fridsma
Douglas B
DB
D003625:Data Collection; D006801:Humans; D008134:Long-Term Care / Q000706:statistics & numerical data*; D008508:Medication Errors / Q000451:nursing* / Q000706:statistics & numerical data*; D008510:Medication Systems, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data; D009740:Nursing Staff / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care / Q000458:organization & administration; D012308:Risk Management / Q000458:organization & administration / Q000706:statistics & numerical data*