HEALTH-SYSTEM EDITION
PROFESSIONAL PRACTICE

Second MedMARx report can help you cut Rx errors

Hospitals and other institutions keep repeating the same medication errors, according to the report Summary of Information Submitted to MedMARx in the Year 2000: Charting a Course for Change. The good news is that they have shown improvement in reporting these errors. The MedMARx report was compiled by the U.S Pharmacopeia (USP) and released to the public last month.

MedMARx is an Internet-accessible, anonymous database that institutions can use to report, track, and trend their medication errors, said Diane Cousins, R.Ph., v.p., practitioner and product experience, USP, Rockville, Md. According to Cousins, more than 500 hospitals subscribe to the MedMARx system.

"Since 1998, we have seen a notable growth in the database," said Cousins. "This is important because there is no other external reporting database that hospitals can access on demand like this." She said the ability to see where errors occurred with the same product at other institutions allows hospitals to design systems with the goal of avoiding the same errors.

Information collected within MedMARx falls into three categories: record detail, product form, and patient profile. When hospitals register with MedMARx, their error-reporting system may not have a compatible structure, said Cousins. "They may need to change the structure of their system to ask for this information up front." Institutions must apply standardized definitions of the terms used in the report, she continued, to create a basis for them to compare their data with data collected at other facilities.

According to the data collected for the year 2000, most medication errors occurred during administration. This does not necessarily mean that most errors actually occur during administration, cautioned Cousins. It simply may mean that hospitals are doing a better job of documenting errors, and that is where they are reported to be occurring most frequently. Similarly, the number of errors originating during the prescribing phase increased by 2% from 1999. Again, she pointed out, it may just mean that institutions are doing a better job of reporting these errors, and the number of errors originating during prescribing did not actually increase.

The three most common types of medication errors for 2000 were omission error, improper dose/quantity, and unauthorized drug. These were also the three most common types of drug errors reported in 1999. Cousins feels the fact that the data are repeating despite a larger data set represents a call to action for pharmacists in terms of where they focus their performance improvement strategies.

The three most common causes of medication errors were performance deficit, procedure/protocol not followed, and transcription inaccurate/omitted. Again, these were also the three most common causes of medication errors reported in 1999. Cousins pointed out that errors caused by computer entry were more common in 2000 than in 1999. In 2000, computer errors were the fifth most common cause of medication errors. In 1999, they ranked seventh. She said that this might mean errors may now be documented in a way that they might not have been prior to the hospital implementing MedMARx.

Insulin, heparin, and morphine were the products most frequently associated with potential and actual medication errors. Cousins said that these drugs have been involved in medication errors throughout the 11 years that the USP has run reporting programs. The findings reinforce that these drugs are error-prone. She feels that this may be because the drugs have complex procedures and protocols associated with their use, and these protocols may not be followed. Pharmacists can evaluate deviations from the protocols to determine what can be done to improve existing protocols or to create protocols where none exist, she said.

MedMARx also looks at actions taken in response to an error, so that hospitals can learn not just about the errors that other institutions made, but also learn what actions they took to prevent them from recurring. Health professionals who initiated or perpetuated the error need to be informed, Cousins said. Those involved need to be made aware of where in the medication dispensing process errors are occurring, and talking to those involved is the best way for the hospital to collect the information necessary to thoroughly study the situation, she continued.

"Pharmacists are the best advocates for medication-error reporting in facilities where MedMARx is used," asserted Cousins. "They can create and implement the medication-error reporting system and educate staff about how to collect and report the information." She believes pharmacists are the most familiar with the kind of information collected and can best understand the importance of collecting such detailed data.

Charlotte LoBuono

Charlotte LoBuono. Second MedMARx report can help you cut Rx errors.

Drug Topics

2002;12:HSE41.