What is the Measure of a Safe Hospital? Medication Errors Missed by Risk Management, Clinical Staff, and SurveyorsGRASSO, BENJAMIN C., MD; ROTHSCHILD, JEFFREY M., MD, MPH; JORDAN, CONSTANCE W., MSN, ANP; JAYARAM, GEETHA, MD, MBAJournal of Psychiatric Practice®: July 2005 - Volume 11 - Issue 4 - p 268-273 Practitioner's Corner Buy SDC Abstract Author InformationAuthors Research in the last decade has identified medication errors as a more frequent cause of unintended harm than was previously thought. Inpatient medication errors and error-prone medication usage are detected internally by medication error reporting and externally through hospital licensing and accreditation surveys. A hospital's rate of medication errors is one of several measures of patient safety available to staff. However, prospective patients and other interested parties must rely upon licensing and accreditation scores, along with varying access to outcome data, as their sole measures of patient safety. We have previously reported that much higher rates of medication errors were found when an independent audit was used compared with rates determined by the usual process of self-report. In this study, we summarize these earlier findings and then compare the error detection sensitivity of licensing and accreditation surveys with that of an independent audit. When experienced surveyors fail to detect a highly error prone medication usage system, it raises questions about the validity of survey scores as a measure of safety (i.e., lack of medication errors). Replication of our findings in other hospital settings is needed. We also recommend measures for improving patient safety by reducing error rates and increasing error detection. GRASSO and JORDAN: The Institute for Self-Directed Care, Falmouth, ME; ROTHSCHILD: Brigham and Women's Hospital, and Harvard Medical School; JAYARAM: Johns Hopkins University School of Medicine. Please send correspondence and reprint requests to: Benjamin C. Grasso MD, Executive Director, The Institute for Self-Directed Care, 3 Fundy Road, Falmouth, Maine 04105. Copyright © 2005 Wolters Kluwer Health, Inc. All rights reserved.