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Online Medication Error Graphic Reports: A Pilot in North Carolina Nursing Homes

Greene, Sandra B. DrPH*; Williams, Charlotte E. MPH*; Pierson, Stephanie MSHI*; Hansen, Richard A. PhD; Carey, Timothy S. MD, MPH*

Journal of Patient Safety: June 2011 - Volume 7 - Issue 2 - p 92-98
doi: 10.1097/PTS.0b013e31821b4eab
Original Articles

Objectives: Since 2003, North Carolina nursing homes have been required by state law to report all medication errors, but the nursing homes have not had usable and timely access to their own error data. We created and pilot tested a new online graphic reporting feature to give homes practical and timely reports on their own reported errors for use in improving medication processes.

Methods: The new graphic reports feature was added to the existing online reporting system and provides immediate access to a set of tables and graphs on all submitted errors. Fifteen nursing homes were recruited to participate in a pilot test of the graphic reports. Key informant interviews were conducted to gather in-depth qualitative information on the use of the reports.

Results: The reports were used primarily for providing information to members of the quality assurance committee and for staff training. Sites had very few technical problems accessing or printing the reports and were able to view them on existing computer systems. Sites with significant numbers of submitted errors in the system reported greater usefulness of the graphics than sites with few errors. Staff turnover at the director of nursing position was the most common reason for low participation at some sites.

Conclusions: The online graphic reports are a positive, user-friendly next step in providing information to the nursing homes to use in improving patient safety. The information is deemed by the users to be the right content, professional in appearance, and accessible to the nursing home.

From the *Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and †Harrison School of Pharmacy, Auburn University, Auburn, Alabama.

Correspondence: Sandra B. Greene, DrPH, Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd. CB 7590, Chapel Hill, NC 27599-7590 (e-mail:

Sources of Support: This project was funded by the Division of Health Service Regulation, Department of Health and Human Services, State of North Carolina (Contract No. 00022236).

The MEQI project has been determined to be exempt from IRB review, IRB number 03-2169.

© 2011 Lippincott Williams & Wilkins, Inc.