Every error a treasure: improving medication use with a nonpunitive reporting system.
BACKGROUND
The fear of reprisal, combined with the additional time required for reporting, are significant disincentives to reporting of medical events. Such considerations provided an incentive for the Upstate Medical University Hospital (Syracuse, New York) to develop monitoring systems to decrease the potential for drug harm. IMPLEMENTING A NONPUNITIVE REPORTING SYSTEM: Previously, a convenient, point-based score card system for punishment and remediation led to underreporting and hindered the identification of safety improvement opportunities in medication use processes. Nursing buy-in was accomplished through careful initial negotiations that emphasized that patients were best served by learning from errors in the medication use process. The revised medication event reporting policy, as established in October 2000 for all staff, severed the link between reporting errors and performance evaluations.


RESULTS
Data collected 18 months before the policy change was compared with data collected after the policy change was enacted in October 2000. The number of reports received each month increased from an average of 19 to 102 (p < .001).


CONCLUSIONS
Substantive quality improvements in medication have been achieved by using a systematic approach to the analysis of the markedly increased number of reported medication events following the introduction of a nonpunitive reporting system.
Lehmann
David F
DF
Department of Medicine, State University of New York Upstate Medical Universtiy, Syracuse, New York, USA. lehmannd@upstate.edu
Page
Nancy
N
Kirschman
Karen
K
Sedore
Ann
A
Guharoy
Roy
R
Medicis
Joseph
J
Ploutz-Snyder
Robert
R
Weinstock
Ruth S
RS
Duggan
David B
DB
D006785:Hospitals, University / Q000592:standards*; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D008510:Medication Systems, Hospital / Q000592:standards*; D009042:Motivation; D009518:New York; D016134:Organizational Policy; D011678:Punishment; D012308:Risk Management / Q000706:statistics & numerical data; D017751:Safety Management / Q000379:methods* / Q000706:statistics & numerical data; D017749:Total Quality Management / Q000379:methods*