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Impact of a Statewide Reporting System on Medication Error Reduction

Rask, Kimberly MD, PhD; Hawley, Jonathan BS; Davis, Anne BSN, MPA; Naylor, Dorothy 'Vi' RN, MN; Thorpe, Kenneth PhD

doi: 10.1097/01.jps.0000226323.37963.19
Original Articles

Objectives: The Partnership for Health and Accountability, a voluntary and peer-review protected statewide hospital patient safety program, was established in Georgia in 2001. One component of this program focuses on safe medication use (SMU) in acute care hospitals. This study evaluated hospital participation in the SMU program, evidence of error reductions, and effectiveness of the program across different types of hospitals.

Methods: Participating hospitals performed a self-assessment, developed an improvement plan to address a specific type of medication error, and then reassessed their results after 9 months of implementation. This study reviewed participating hospital surveys from 2001, 2002, and 2003.

Results: Hospital participation rates were high (more than 90% of eligible hospitals) in each year. Dose omission was the most common error type addressed by participating hospitals. Human factors, frequent interruptions, and communication issues were identified as the most common contributors to errors. Most hospitals relied on incident reports to identify errors; however, a small but growing number of hospitals are using automated or computer-generated reports. Most hospitals did reduce the targeted medication error, with a mean error reduction of 28% in 2002 and 34% in 2003. Improvement was seen across all types of hospitals, with no statistically significant differences between urban, rural, large, small, or academic hospitals. Overall participation in the statewide patient safety program was the only significant predictor of both the likelihood and magnitude of error reduction.

Conclusions: Hospital participation rates were high in this voluntary program. Institutional commitment to the overall patient safety initiative was the only hospital characteristic that predicted success in reducing medication errors. Hospital willingness to share negative results is a strong validation of the nonpunitive environment. The SMU program was effective across a diverse mix of hospitals, including small and rural hospitals, and should be considered in other states.

From the *Emory Center on Health Outcomes and Quality, Rollins School of Public Health, Atlanta; and the †Georgia Hospital Association, Marietta, Georgia.

Correspondence: Kimberly Rask, MD, PhD, Associate Professor of Health Policy and Management, Rollins School of Public Health, 1518 Clifton Road, NE, Atlanta, GA 30322 (e-mail:

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