Re-engineering the medication error-reporting process: removing the blame and improving the system

A hospital's change from a traditional, multitiered incident-reporting system for medication errors to a standardized, nonpunitive medication-use variance process is described. After weaknesses were identified in the hospital's system for reporting and evaluating medication errors, a multidisciplinary task force was formed to redesign the hospital's medication error-reporting system. Its guiding principles were as follows: anonymity and freedom from punitive action are essential for increasing the number of reports, rating medication errors facilitates identification of areas for system improvement, potential errors provide valuable insight into the system's vulnerabilities, and timely review of reports enables rapid systematic correction. To support the intended nonpunitive culture, the term medication-use variance was used in lieu of medication error for any unplanned event that deviates from the intended course of prescribing, dispensing, administering, or monitoring medications. A one-page medication-use variance report was developed that prompted the reporter for key data elements, including root causes, patient outcomes, and possible ways to prevent similar incidents. The most difficult decision for the task force was deciding whether the process should be anonymous. After getting the support of the medical-legal counsel and the quality improvement department for an anonymous reporting process, the task force agreed to test it in the department of pharmacy and in three patient units in September 1998. A paper-driven reporting process was selected initially because an electronic system would not be truly anonymous. The number of reports from these units increased compared with historical trends, and for the first time potential errors were reported. The report form was easy to use and improved the interpretation of reports. Despite these positive results, task force members remained divided on the issue of anonymity but ultimately embraced the nonpunitive culture. In the first six months following hospitalwide implementation, the number of events captured increased more than fivefold; it continues to increase. The resulting database serves as a trigger for quality improvement efforts and a measure of their effectiveness. The redesign of the medication error-reporting process served as the impetus for a change in the organizational culture surrounding medication errors.