Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system.
OBJECTIVE
To describe the implementation and evaluation of a web-based medication error reporting system.


METHODS
Evaluation study.


METHODS
Long-term care.


METHODS
25 nursing homes in the US state of North Carolina.


METHODS
Detailed information about all medication errors occurring in a facility during a 1 year period was entered into a web-based reporting system. An evaluation survey was conducted to assess usability and the potential for the system to prevent errors.


METHODS
Number and specific characteristics of medication errors reported. A survey evaluating ease of use of the system and whether the participants thought it would help improve medication safety.


RESULTS
23 (92%) sites entered 631 error reports for 2731 discrete error instances when weighted by the number of times the errors were repeated. 51 (8%) errors were classified as having a serious patient impact requiring monitoring/intervention or worse. The most common errors were dose omission (203, 32%), overdose (91, 14%), underdose (43, 7%), wrong patient (38, 6%), wrong product (38, 6%), and wrong strength (38, 6%). Errors most commonly occurred during medication administration (296, 47%) and were attributed to basic human error (402, 48%). Seven drugs were implicated in a third (175, 28%) of all errors: lorazepam, oxycodone, warfarin, furosemide, hydrocodone, insulin and fentanyl. 20 sites (86% of respondents) completed the evaluation survey and participants found the system easy to use and thought it would increase accuracy of reporting and improve patient safety.


CONCLUSIONS
The web-based medication error reporting system was easy to use, with strong indications that it would be a valuable tool for preventing future errors.
Pierson
Stephanie
S
Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7590, USA. pierson@unc.edu
Hansen
Richard
R
Greene
Sandra
S
Williams
Charlotte
C
Akers
Roger
R
Jonsson
Mattias
M
Carey
Timothy
T
D016303:Clinical Pharmacy Information Systems; D005240:Feasibility Studies; D019538:Health Care Surveys; D006284:Health Plan Implementation; D006801:Humans; D020407:Internet / Q000706:statistics & numerical data*; D008134:Long-Term Care / Q000592:standards*; D008331:Management Information Systems; D008508:Medication Errors / Q000145:classification / Q000517:prevention & control* / Q000706:statistics & numerical data; D009657:North Carolina; D009735:Nursing Homes / Q000592:standards*; D009936:Organizational Innovation; D012308:Risk Management / Q000379:methods*
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