Desiree L Kunac1, Michael V Tatley, Mary E Seddon. 1. New Zealand Pharmacovigilance Centre, Department of Preventive and Social Medicine, University of Otago. PO Box 913, Dunedin 9054, New Zealand. desiree.kunac@otago.ac.nz.
Abstract
AIMS: To determine if primary care clinicians would report medication errors using a new web-based system, and to obtain data illustrating the potential of the information collected to improve medication safety. METHOD: The New Zealand Pharmacovigilance Centre led the development of the Medication Error Reporting Programme (MERP) which was then piloted over an 8- month period involving 38 general practice and 28 community pharmacy staff. The Pharmacy Defence Association also contributed dispensing error claims. An analysis of the characteristics of errors was undertaken. RESULTS: A total of 376 reports were submitted; 55 (15%) reported patient harm, 1 of which required lifesaving intervention. The therapeutic groups most commonly implicated were medicines for managing 'nervous' and 'cardiovascular' systems. Wrong dose (25%) and wrong medicine (22%) were the most common error types, occurring predominantly with the prescribing and dispensing of medications. The most frequent contributing factors to errors in general practice were problems in the process of prescribing whereas in community pharmacy they related to product name and packaging factors. Time pressures, workload and interruptions were commonly cited for both settings. CONCLUSION: Primary care clinicians who volunteered for the pilot were willing and able to use the MERP system to report medication errors. The standardised data obtained through MERP enables rapid analysis and has the potential to inform initiatives for improving patient safety.
AIMS: To determine if primary care clinicians would report medication errors using a new web-based system, and to obtain data illustrating the potential of the information collected to improve medication safety. METHOD: The New Zealand Pharmacovigilance Centre led the development of the Medication Error Reporting Programme (MERP) which was then piloted over an 8- month period involving 38 general practice and 28 community pharmacy staff. The Pharmacy Defence Association also contributed dispensing error claims. An analysis of the characteristics of errors was undertaken. RESULTS: A total of 376 reports were submitted; 55 (15%) reported patient harm, 1 of which required lifesaving intervention. The therapeutic groups most commonly implicated were medicines for managing 'nervous' and 'cardiovascular' systems. Wrong dose (25%) and wrong medicine (22%) were the most common error types, occurring predominantly with the prescribing and dispensing of medications. The most frequent contributing factors to errors in general practice were problems in the process of prescribing whereas in community pharmacy they related to product name and packaging factors. Time pressures, workload and interruptions were commonly cited for both settings. CONCLUSION: Primary care clinicians who volunteered for the pilot were willing and able to use the MERP system to report medication errors. The standardised data obtained through MERP enables rapid analysis and has the potential to inform initiatives for improving patient safety.
Authors: Carrie E Pierce; Khaled Bouri; Carol Pamer; Scott Proestel; Harold W Rodriguez; Hoa Van Le; Clark C Freifeld; John S Brownstein; Mark Walderhaug; I Ralph Edwards; Nabarun Dasgupta Journal: Drug Saf Date: 2017-04 Impact factor: 5.606