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Perceived Barriers in Using a Region-Wide Medication Error Reporting System

Coley, Kim C. PharmD*; Pringle, Janice L. PhD*; Weber, Robert J. MS*; Rice, Kristen BS, BA*; Ramanujam, Rangaraj PhD, MBA†; Sirio, Carl A. MD‡

Original Articles

Abstract: The objective of this study was to evaluate the perceived barriers to using a region-wide medication error reporting system. This was a qualitative analysis of representatives from 8 hospitals: 2 urban, 4 community, 1 long-term care, and 1 pediatric. Participants were involved with at least one aspect of error reporting (i.e., data collection, report utilization) at their institution. Information was obtained on barriers to medication error reporting and use of a regional quarterly error report. Participants consistently identified 4 obstacles to medication error reporting and use of the quarterly report. First, few hospitals had sufficient dedicated staff for identification, verification, and reporting of errors. Efforts to promote reporting were compromised by other demands on staff time. Next, information systems in most hospitals were fragmented, leading to duplication of efforts and inefficiency. Concerns were also expressed about benchmarking by hospital administrators and reactions to increases in error reporting. Finally, hospitals can generate internal error reports for analyses faster than they would receive the quarterly reports. These last 2 issues had a negative impact on report utilization and dissemination. This study identified ongoing obstacles to increased reporting and data sharing that must be addressed to improve patient safety across a region.

From the *Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania; †Krannert School of Management, Purdue University, West Lafayette, Indiana; and ‡Department of Critical Care Medicine and Pharmacy and Therapeutics, University of Pittsburgh Schools of Medicine and Pharmacy, Pittsburgh, Pennsylvania.

Correspondence: Kim C. Coley, PharmD, University of Pittsburgh School of Pharmacy, Pittsburgh, PA.

© 2006 Lippincott Williams & Wilkins, Inc.