JAMDA
Volume 8, Issue 9 , Pages 568-574 , November 2007

Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting

  • Steven M. Handler, MD, MS

      Affiliations

    • Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
    • Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA
    • Corresponding Author InformationAddress correspondence to Steven M. Handler, MD, MS, Division of Geriatric Medicine, University of Pittsburgh, 3471 Fifth Ave, Suite 500, Pittsburgh, PA 15213.
    • ,
  • Subashan Perera, PhD

      Affiliations

    • Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
    • Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
    • ,
  • Ellen F. Olshansky, DNSc, RNC

      Affiliations

    • Program in Nursing Science, College of Health Sciences, University of California, Irvine, Irvine, CA
    • ,
  • Stephanie A. Studenski, MD, MPH

      Affiliations

    • Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
    • Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System (VAPHS), Pittsburgh, PA
    • ,
  • David A. Nace, MD, MPH

      Affiliations

    • Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
    • ,
  • Douglas B. Fridsma, MD, PhD

      Affiliations

    • Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA
    • ,
  • Joseph T. Hanlon, PharmD, MS

      Affiliations

    • Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
    • Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System (VAPHS), Pittsburgh, PA
    • Department of Pharmacy and Therapeutics, School of Pharmacy, University Pittsburgh, Pittsburgh, PA
    • Center for Health Equity Research and Promotion (CHERP), VAPHS, Pittsburgh, PA.

References 

  1. National Coordinating Council for Medication Error Reporting and Prevention. What is a Medication Error? Available at: http://www.nccmerp.org/aboutMedErrors.html. Accessed January 10, 2006.
  2. Institute of Medicine. Preventing Medication Errors. Washington, DC: National Academies Press; 2006;
  3. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000;
  4. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162(16):1897–1903
  5. Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing facilities. Arch Intern Med. 1997;157(18):2089–2096
  6. Murff HJ, Patel VL, Hripcsak G, Bates DW. Detecting adverse events for patient safety research: a review of current methodologies. J Biomed Inform. 2003;36(1–2):131–143
  7. Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002;59(5):436–446
  8. Dimant J. Medication errors and adverse drug events in nursing homes: Problems, causes, regulations, and proposed solutions. J Am Med Dir Assoc. 2001;2(March/April):81–93
  9. Handler SM, Nace DA, Studenski SA, Fridsma DB. Medication error reporting in long-term care. Am J Geriatr Pharmacother. 2004;2(3):190–196
  10. Wagner LM, Capezuti E, Ouslander JG. Reporting near-miss events in nursing homes. Nurs Outlook. 2006;54(2):85–93
  11. Leape LL. Reporting of adverse events. N Engl J Med. 2002;347(20):1633–1638
  12. In:  Cohen MR editors. Medication Errors: Causes, Prevention, and Risk Management. Washington, DC: American Pharmaceutical Association; 1999;
  13. Delbecq AL, Van de Ven AH, Gustafson DH. Group Techniques for Program Planning: A guide to nominal group and delphi processses. Glenview, IL: Scott Foresman; 1975;
  14. Goeman DP, Hogan CD, Aroni RA, et al. Barriers to delivering asthma care: A qualitative study of general practitioners. Med J Aust. 2005;183(9):457–460
  15. Hickling J, Rogers S, Nazareth I. Barriers to detecting and treating hypercholesterolaemia in patients with ischaemic heart disease: Primary care perceptions. Br J Gen Pract. 2005;55(516):534–538
  16. Levine DA, Saag KG, Casebeer LL, Colon-Emeric C, Lyles KW, Shewchuk RM. Using a modified nominal group technique to elicit director of nursing input for an osteoporosis intervention. J Am Med Dir Assoc. 2006;7(7):420–425
  17. Studenski S, Hayes RP, Leibowitz RQ, et al. Clinical Global Impression of Change in Physical Frailty: Development of a measure based on clinical judgment. J Am Geriatr Soc. 2004;52(9):1560–1566
  18. Gallagher M, Hares T, Spencer J, Bradshaw C, Webb I. The nominal group technique: A research tool for general practice?. Fam Pract. 1993;10(1):76–81
  19. Dunham RB. Nominal Group Technique: A User’s Guide. Available at: http://instruction.bus.wisc.edu/obdemo/readings/ngt.html. Accessed May 7, 2007.
  20. Uribe CL, Schweikhart SB, Pathak DS, Dow M, Marsh GB. Perceived barriers to medical-error reporting: An exploratory investigation. J Healthc Manag. 2002;47(4):263–279
  21. Leape LL, Berwick DM. Five years after To Err Is Human: What have we learned?. JAMA. 2005;293(19):2384–2390
  22. Reason JT, Carthey J, de Leval MR. Diagnosing “vulnerable system syndrome”: An essential prerequisite to effective risk management. Qual Health Care. 2001;10(Suppl 2):ii21–ii25
  23. Nolan TW. System changes to improve patient safety. BMJ. 2000;320(7237):771–773
  24. Joshi MS, Anderson JF, Marwaha S. A systems approach to improving error reporting. J Healthc Inf Manag. 2002;16(1):40–45
  25. Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15(1):39–43
  26. Jeffe DB, Dunagan WC, Garbutt J, et al. Using focus groups to understand physicians’ and nurses’ perspectives on error reporting in hospitals. Jt Comm J Qual Saf. 2004;30(9):471–479
  27. Kingston MJ, Evans SM, Smith BJ, Berry JG. Attitudes of doctors and nurses towards incident reporting: A qualitative analysis. Med J Aust. 2004;181(1):36–39
  28. Handler S, Castle N, Studenski S, et al. Patient safety culture assessment in the nursing home. Qual Saf Health Care. 2006;15(4):400–404
  29. Castle NG, Sonon KE. A culture of patient safety in nursing homes. Qual Saf Health Care. 2006;15(6):405–408
  30. Hughes CM, Lapane KL. Nurses’ and nursing assistants’ perceptions of patient safety culture in nursing homes. Int J Qual Health Care. 2006;18(4):281–286
  31. Edwards P, Roberts I, Clarke M, et al. Increasing response rates to postal questionnaires: systematic review. BMJ. 2002;324(7347):1183
  32. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50(10):1129–1136
  33. Castle NG. Measuring staff turnover in nursing homes. Gerontologist. 2006;46(2):210–219
  34. Cafiero AC. Reducing medication errors in a long-term care setting. Annals of Long-Term Care. 2003;11(2):29–35
  35. Greene SB, Williams CE, Hansen R, Crook K, Akers R, Carey TS. Medication errors in nursing homes: A state’s experience implementing a reporting system. Journal of Patient Safety. 2005;1(4):181–189
  36. Hansen RA, Greene SB, Williams CE, et al. Types of medication errors in North Carolina nursing homes: a target for quality improvement. Am J Geriatr Pharmacother. 2006;4(1):52–61
  37. Carroll-Solomon PA, Denny DS. A real-time medical event reporting and prevention system in long-term care. J Healthc Qual. 2005;27(2):4–11
  38. Sirio CA, Segel KT, Keyser DJ, et al. Pittsburgh Regional Healthcare Initiative: A systems approach to achieving perfect patient care. Health Aff (Millwood). 2003;22(5):157–165
  39. Kessler DA. Introducing MEDWatch (A new approach to reporting medication and device adverse effects and product problems). JAMA. 1993;269(21):2765–2768
  40. Edgar TA, Lee DS, Cousins DD. Experience with a national medication error reporting program. Am J Hosp Pharm. 1994;51(10):1335–1338
  41. Santell JP, Hicks RW, McMeekin J, Cousins DD. Medication errors: Experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol. 2003;43(7):760–767
  42. Savage SW, Schneider PJ, Pedersen CA. Utility of an online medication-error-reporting system. Am J Health Syst Pharm. 2005;62(21):2265–2270
  43. Handler SM, Wright RM, Ruby CM, Hanlon JT. Epidemiology of medication-related adverse events in nursing homes. Am J Geriatr Pharmacother. 2006;4(3):264–272
  44. Bates DW, Evans RS, Murff H, Stetson PD, Pizziferri L, Hripcsak G. Detecting adverse events using information technology. J Am Med Inform Assoc. 2003;10(2):115–128
  45. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003;348(25):2526–2534

 This study was supported in part by an American Medical Directors Association Foundation/Pfizer Quality Improvement Award, by a Merck/AFAR Junior Investigator Award in Geriatric Clinical Pharmacology, and by NIH grants 1K12HD049109–01, 5T32AG021885, P30-AG024827, and AG027017.

PII: S1525-8610(07)00307-6

doi: 10.1016/j.jamda.2007.06.009

JAMDA
Volume 8, Issue 9 , Pages 568-574 , November 2007

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