title: Reporting trends in a regional medication error data-sharing system.
abstract: Inter-organizational systems for sharing data about medication errors have emerged as an important strategy for improving patient safety and are expected to encourage not only voluntary error reporting but also learning from errors. Yet, few studies have examined the hypothesized benefits of inter-organizational data sharing. The current study examined the developmental trends in information reported by hospitals participating in a regional reporting system for medication errors. A coalition of hospitals in southwestern Pennsylvania, under the auspices of the Pittsburgh Regional Healthcare Initiative (PRHI), implemented a voluntary system for quarterly sharing of information about medication errors. Over a 12-month period, 25 hospitals shared information about 17,000 medication errors. Using latent growth curve analysis, we examined longitudinal trends in the quarterly number of errors and associated corrective actions reported by each hospital. Controlling for size, teaching status, and JCAHO accreditation score, for the hospitals as a group, error reporting increased at a statistically significant rate over the four quarters. Moreover, despite significant baseline differences among hospitals, error reporting increased at similar rates across hospitals over subsequent quarters. In contrast, the reporting of corrective actions remained unchanged. However, the baseline levels of corrective actions reporting were significantly different across hospitals. Although data sharing systems promote error reporting, it is unclear whether they encourage corrective actions. If data sharing is intended to promote not just error reporting but also root-cause-analysis and process improvement, then the design of the reporting system should emphasize data about these processes as well as errors.
authors.affiliation: Department of Sociology, Purdue University, West Lafayette, IN 47907-2059, USA. Andersonj@purdue.edu
authors.forename: James G
authors.initials: JG
authors.lastname: Anderson
authors.forename: Rangaraj
authors.initials: R
authors.lastname: Ramanujam
authors.forename: Devon J
authors.initials: DJ
authors.lastname: Hensel
authors.forename: Carl A
authors.initials: CA
authors.lastname: Sirio
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems / Q000706:statistics & numerical data; D006801:Humans; D008137:Longitudinal Studies; D008508:Medication Errors / Q000706:statistics & numerical data*; D008510:Medication Systems, Hospital / Q000706:statistics & numerical data*; D015233:Models, Statistical; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care; D012308:Risk Management; D014481:United States
references.citation: N Engl J Med. 2002 Nov 14;347(20):1633-8
references.pmid: 12432059
references.citation: JAMA. 2005 May 18;293(19):2384-90
references.pmid: 15900009
references.citation: JAMA. 1991 Nov 27;266(20):2847-51
references.pmid: 1942452
references.citation: J Am Med Inform Assoc. 2005 Nov-Dec;12(6):596-601
references.pmid: 16049225
references.citation: Health Aff (Millwood). 2003 Sep-Oct;22(5):157-65
references.pmid: 14515891
references.citation: N Engl J Med. 2004 Nov 11;351(20):2041-3
references.pmid: 15537902
references.citation: Jt Comm J Qual Improv. 1995 Oct;21(10):541-8
references.pmid: 8556111
references.citation: BMJ. 2000 Mar 18;320(7237):791-4
references.pmid: 10720370
references.citation: Health Aff (Millwood). 2004 Jul-Dec;Suppl Web Exclusives:W4-534-45
references.pmid: 15572380
references.citation: Health Aff (Millwood). 2005 Jan-Feb;24(1):138-50
references.pmid: 15647225