Variability in Threshold for Medication Error Reporting Between Physicians, Nurses, Pharmacists, and Families

Keefer, Patricia; Kidwell, Kelley M.; Lengyel, Candice; Warrier, Kavita; Wagner, Deborah

doi:10.2174/1574886312666170724163439

Cited by 3 publications

(5 citation statements)

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“…In line with components of the COM-B model, capability, opportunity and motivation to report were found to be strongly influenced by organisation context and resources, the wider primary care setting as well as more entrenched views about professional roles and responsibilities. Our findings thereby concur with previous evidence around the impact of wider and complex sociocultural, organisational and political processes and agendas relating to professional practice, regulation, social inequalities, control and power 27–29. A climate of fear within the NHS37 and need for trust of and understanding by regulatory authorities38 have previously been described and were also mentioned as influences on reporting by our participants.…”

Section: Discussionsupporting

confidence: 91%

“…These include: awareness and functionality of incident reporting systems;23 24 the need to clarify reporting criteria;25 and sociocultural, organisational and political processes and agendas relating to professional practice, regulation, social inequalities, control and power 26–28. Personal thresholds for reporting have also been shown to vary within and between health professions,29 30 and evidence suggests that medication error reporting rates can improve with intervention,31 32 although sustainability beyond trial settings is less clear.…”

Section: Introductionmentioning

confidence: 99%

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Exploration of prescribing error reporting across primary care: a qualitative study

et al. 2022

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ObjectivesTo explore barriers and facilitators to prescribing error reporting across primary care.DesignQualitative semi-structured face-to-face and telephone interviews were conducted to explore facilitators and barriers to reporting prescribing errors. Data collection and thematic analysis were informed by the COM-B model of behaviour change. Framework analysis was used for coding and charting the data with the assistance of NVivo software (V.12). General and context specific influences on prescribing error reporting were mapped to constructs from the COM-B model (ie, capability, opportunity and motivation).SettingPrimary care organisations, including community pharmacy, general practice and community care from North East England.ParticipantsWe interviewed a maximal variation purposive sample of 25 participants, including prescribers, community pharmacists and key stakeholders with primary care or medicines safety roles at local, regional and national levels.ResultsOur findings describe a range of factors that influence the capability, opportunity and motivation to report prescribing errors in primary care. Three key contextual factors are also highlighted that were found to underpin many of the behavioural influences on reporting in this setting: the nature of prescribing; heterogeneous priorities for error reporting across and within different primary care organisations; and the complex infrastructure of reporting and learning pathways across primary care. Findings suggest that there is a lack of consistency in how, when and by whom, prescribing errors are reported across primary care.ConclusionsFurther research is needed to identify cross-organisational and interprofessional consensus on agreed reporting thresholds and how best to facilitate a more collaborative approach to reporting and learning, that is, sensitive to the needs and priorities of disparate organisations across primary care. Despite acknowledged challenges, there may be potential for an increased role of community pharmacy in prescribing error reporting to support future learning.

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Section: Discussionsupporting

confidence: 91%

Section: Introductionmentioning

confidence: 99%

Exploration of prescribing error reporting across primary care: a qualitative study

et al. 2022

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“…reported a study to investigate the quality differences of medication errors reporting among physicians, nurses, pharmacists, and families and emphasized the need for training about reporting of drug errors. [35] The results of our study showed that pharmacists had played a significant role in finding and documented drug prescription problems with a report proportion of >80% of DRPs and indicate the necessity of further information and training to other health service providers including physicians and nurses.…”

Section: Discussionmentioning

confidence: 87%

The responsibility of clinical pharmacists for the safety of medication use in hospitalized children: A Middle Eastern experience

et al. 2019

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Objective: We aimed to detect and report the frequency of occurrence of drug-related problems (DRPs) in a Middle Eastern University Children's Hospital (Isfahan, Iran) and classify them in terms of their nature and cause to clarify the responsibility of clinical pharmacists for the safe utilization of medications in hospitalized children. Methods: In this cross-sectional study which was carried out in Imam Hossein Children's University Hospital affiliated with Isfahan University of Medical Sciences (Isfahan, Iran) from September 2017 to May 2018, DRPs during the hospitalization of pediatric patients in three medical wards, the pediatric intensive care unit, and two neonatal intensive care units were detected and identified concurrently with the treatment process using Pharmaceutical Care Network of Europe data gathering form for DRPs v. 8.01. All cases were verified and validated in a professional focus group before documentation. Findings: We detected 427 DRPs in 201 out of 250 randomly included hospitalized children in which 86% of them were directly reported by the hospital's clinical pharmacist. The highest frequency of DRPs (47.3%) was observed in the age range of 1 month–2 years. Safety of treatment was the most frequently reported as the nature of the problem (43.5%), followed by effectiveness issues (36.8%). The most frequent cause of DRPs was dose selection issues (34.2%), followed by drug-type selection (25.5%), and unavailability of appropriate dosage forms (13.6%). Ninety-eight interventions were proposed by the clinical pharmacist, in which 59.2% of them were accepted. Conclusion: This study confirms the necessity for the active role of clinical pharmacists before, during, and after drug therapy in hospitalized pediatric patients for the safety and proper utilization of drugs in this vulnerable population.

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“…There is also evidence to suggest that error reporting thresholds differ between different healthcare professionals and individuals make their own interpretations about what, when and how to report a prescribing error. 15 28 38–41 This includes lowering the priority for those which resulted in no harm to the patient or near miss incidents, 41 especially those that could be resolved through communication with the prescriber, pharmacist and patient. 15 This was also identified with hospital pharmacists, where the severity of the medication error was a major factor in deciding to report.…”

Section: Discussionmentioning

confidence: 99%

“… 12 22 43 Recurrent training and feedback is therefore essential to ensure that any intervention that aims to improve reporting are using a consistent approach. 41 42 …”

Section: Discussionmentioning

confidence: 99%

Prescribing error reporting in primary care: a narrative synthesis systematic reviewPrescribing error reporting in primary care: a narrative synthesis systematic review

Bullen

Hall

Sherwood

et al. 2020

Integrated Healthcare Journal

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Prescribing errors can cause avoidable harm to patients. Most prescriptions originate in primary care, where medications tend to be self-administered and errors have the most potential to cause harm. Reporting prescribing errors can identify trends and reduce the risk of the reoccurrence of incidents; however, under-reporting is common. The organisation of care and the movement of prescriptions from general practice to community pharmacy may create difficulties for professionals to effectively report errors.This review aims specifically to identify primary research studies that examine barriers and facilitators to prescription error reporting across primary care. A systematic research of the literature was completed in July 2019. Four databases (PubMed/Medline, Cochrane, CINAHL and Web of Science) were searched for relevant studies. No date or language limits were applied. Eligible studies were critically appraised using the Mixed Methods Appraisal Tool, and data were descriptively and narratively synthesised.Ten articles were included in the final analysis. Seven studies considered prescription errors and error reporting within general practice and three within a community pharmacy setting. Findings from the included studies are presented across five themes, including definition of an error, prescribing error reporting culture, reporting processes, communication and capacity.Healthcare professionals appreciate the value of prescription error reporting, but there are key barriers to implementation, including time, fear of reprisal and organisation separation within primary care.

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Variability in Threshold for Medication Error Reporting Between Physicians, Nurses, Pharmacists, and Families

Abstract: There is significant variability in the threshold to report specific medication errors in the hospital setting. More work needs to be done to further improve the education surrounding error reporting in hospitals for all noted subgroups.

Cited by 3 publications

References 0 publications

Exploration of prescribing error reporting across primary care: a qualitative study

Exploration of prescribing error reporting across primary care: a qualitative study

The responsibility of clinical pharmacists for the safety of medication use in hospitalized children: A Middle Eastern experience

Prescribing error reporting in primary care: a narrative synthesis systematic reviewPrescribing error reporting in primary care: a narrative synthesis systematic review

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