Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System--MEADERS.
OBJECTIVE
In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices.


METHODS
We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports.


RESULTS
A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting.


CONCLUSIONS
It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.
Department of Family Medicine and the Medicine Institute, Cleveland Clinic, Cleveland, OH 44195, USA. hicknej@ccf.org
John
J
Hickner
Atif
A
Zafar
Grace M
GM
Kuo
Lyle J
LJ
Fagnan
Samuel N
SN
Forjuoh
Lyndee M
LM
Knox
John T
JT
Lynch
Brian Kelly
BK
Stevens
Wilson D
WD
Pace
Benjamin N
BN
Hamlin
Hilary
H
Scherer
Brenda L
BL
Hudson
Caitlin Carroll
CC
Oppenheimer
William M
WM
Tierney
D016907:Adverse Drug Reaction Reporting Systems / Q000458:organization & administration / Q000706:statistics & numerical data*; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D005240:Feasibility Studies; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D009862:Online Systems; D010865:Pilot Projects; D011320:Primary Health Care / Q000706:statistics & numerical data*; D011787:Quality of Health Care / Q000706:statistics & numerical data; D012308:Risk Management; D011795:Surveys and Questionnaires; D014481:United States