Nonpunitive medication error reporting: 3-year findings from one hospital's Primum Non Nocere initiative.
OBJECTIVE
To identify underlying practices and attitudes on medication error occurrences and reporting practices.


BACKGROUND
In response to a hospital-wide quality improvement initiative, a task force was formed to facilitate a nonpunitive culture toward reporting medication errors. To identify underlying practices and attitudes on medication errors and medication error reporting, a baseline survey was conducted. Based on findings, an initiative that included modifications to clinical and administrative processes was developed and implemented.


METHODS
A pre/post initiative questionnaire to measure staff practices and attitudes on medication error reporting was developed and administered. Findings from the presurvey were used to craft the Nonpunitive Patient Safety Policy and its implementation plan. Pre-post comparative analysis was performed following a baseline-postimplementation design.


RESULTS
Conceptually, a medication error is qualified by its outcome severity. Medication errors with more serious outcomes are more likely to be reported than those with less serious ones. Staff perception that medication error reporting carries the risks of disciplinary action was identified as a primary barrier to the likelihood of reporting.


CONCLUSIONS
Evaluation of the initiative suggests that a multicomponent approach facilitates positive movement in the direction of a nonpunitive culture toward reporting medication errors.
Potylycki
Mary Jean
MJ
Lehigh Valley Hospital and Health Network, Allentown, PA 18107, USA.
Kimmel
Sharon R
SR
Ritter
Marlene
M
Capuano
Terry
T
Gross
LaDene
L
Riegel-Gross
Kelly
K
Panik
Anne
A
D001291:Attitude of Health Personnel; D004509:Education, Nursing, Continuing / Q000458:organization & administration; D004647:Employee Discipline; D019317:Evidence-Based Medicine; D007722:Health Knowledge, Attitudes, Practice; D006301:Health Services Needs and Demand; D006801:Humans; D007318:Inservice Training / Q000458:organization & administration; D008508:Medication Errors / Q000009:adverse effects / Q000451:nursing / Q000517:prevention & control* / Q000706:statistics & numerical data; D015969:National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division; D015401:Nursing Administration Research; D015402:Nursing Education Research; D015404:Nursing Methodology Research; D009741:Nursing Staff, Hospital / Q000193:education / Q000523:psychology; D015279:Organizational Culture; D016134:Organizational Policy; D010414:Pennsylvania; D016730:Program Development; D015397:Program Evaluation; D011678:Punishment / Q000523:psychology; D012308:Risk Management / Q000458:organization & administration*; D017749:Total Quality Management / Q000458:organization & administration*; D014481:United States