Implementing and Evaluating a
Program of Patient Safety
Successful Reporting
Systems as the Foundation
Katherine Jones, PhD, PT
Anne Skinner, RHIA
Gary Cochran, PharmD
Keith Mueller, PhD
Supported by AHRQ Grant 1 U18 HS015822
Objectives
Explain the role of voluntary reporting systems in a
program of patient safety
 Identify the characteristics of successful reporting
systems
 Identify information necessary for systematic data
collection in a medication error reporting program
 Understand how the NCC MERP Taxonomy of
error severity provides a language to describe errors
in the context of a system

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The Problem…
“The problem is not bad people; the
problem is that the system needs to
be made safer . . . Voluntary
reporting systems are an important
part of an overall program for
improving patient safety and . . .
have a very important role to play in
enhancing an understanding of the
factors that contribute to errors.”
To Err is Human: Building a Safer Health
System
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Reporting is the foundation of a
culture of safety
“Any safety information system depends
crucially on the willing participation of the
workforce, the people in direct contact with
the hazards. To achieve this, it is necessary to
engineer a reporting culture—an organization in
which people are prepared to report their
errors and near-misses.”
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Components of Safety Culture
INFORMED = SAFE
A culture of
safety is
informed. It
never forgets
to be afraid…
LEARNING
FLEXIBLE
JUST
REPORTING
Reason, J. Managing the Risks of Organizational Accidents.
Hampshire, England: Ashgate Publishing Limited; 1997.
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Reporting is supported by just,
flexible, and learning cultures

The willingness of workers to report depends on their
belief that management will support and reward reporting
and that discipline occurs based on risk-taking…there is a
clear line between acceptable and unacceptable behavior
workers—organizational practices support a just culture.

The willingness of workers to report depends on their
belief that authority patterns relax when safety information
is exchanged because managers respect the knowledge of
front-line workers—organizational practices support a
flexible culture.
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Reporting is supported by just,
flexible, and learning cultures

Ultimately, the willingness of workers to report depends
on their belief that the organization will analyze reported
information and then implement appropriate change—
organizational practices support a learning culture.

The interaction of practices that support reporting, just,
flexible, and learning cultures produces an informed, safe
organization that is highly reliable.

The organizational beliefs and practices associated with
these components of culture are assessed by the AHRQ
HSOPSC.
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Characteristics of Successful Reporting
Systems
Nonpunitive: reporters do not fear punishment as a result
of reporting
 Confidential: identities of reporter, patient, institution are
never revealed to a 3rd party
 Independent: reporting is independent of any authority
who has the power to discipline the reporter
 Expert analysis: reports are analyzed by those who have
the knowledge to recognize underlying system causes of error
 Timely: reports are analyzed promptly and
recommendations disseminated rapidly
 Systems-oriented: recommendations focus on systems
not individuals
 Responsive: those receiving reports are capable of
disseminating recommendations

Leape, LL. (2002). Reporting of adverse events. NEJM, 347, p. 1636.
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MEDMARX®
MEDMARX is an anonymous medication error reporting
program that subscribing hospitals and health systems
participate in as part of their ongoing quality
improvement initiatives. Nationally, data from
MEDMARX contributes to knowledge about the causes
and prevention of medication errors. Over 870 hospitals
and health systems have submitted more than 1.3 million
medication error records to MEDMARX. Analyses of
voluntary medication error reports from large patient
safety databases, such as MEDMARX, can identify system
sources of error and lead to the establishment of safe
medication practices.
Stevenson JG. Medication errors: Experience of the United States Pharmacopeia.
Jt Comm J Qual Safe 2005;31(2):106-111.
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www.MEDMARX.com
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Systematic Data Collection in
Medication Error Reporting







Error severity based on the outcome to patient
Description of the error
Phase of the medication use process in which the
error originates
Type of the error
Cause of the error
Contributing factors to the error
Information about the drug(s) involved
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NCC MERP Taxonomy of Error
Severity









A: capacity to cause error
B: error occurred, did not reach patient
C: error reached patient, no harm
D: error reached patient, monitoring and intervention
required
E: temporary harm requiring intervention
F: temporary harm requiring initial or prolonged
hospitalization
G: permanent harm
H: intervention required to sustain life
I: error contributed to or resulted in death
http://www.nccmerp.org/pdf/taxo2001-07-31.pdf
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Reporting Error Severity
Error Severity Jan - June 2007 (31 CAHs submitted 2,799 reports)
D (reaches pt,
monitoring)
2%
E (temporary harm)
0%
F (harm,
hospitalization)
0%
A (potential error)
28%
C (reaches pt, no
harm)
50%
B (near-miss)
20%
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Reporting Where Errors Originate
Phase of Error Origination Jan - June 2007 (31 CAHs submitted 2,799 reports)
Monitoring
0%
Procurement
1%
Prescribing
5%
Documenting
26%
Administering
58%
Dispensing
10%
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Reporting
Types of
Errors
Jones et al. (2006).
http://www.unmc.
edu/rural/documents/p
r06-08.pdf
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17
Similar products
Dosage form
confusion
Knowledge deficit
Dispensing device
2006 (35 CAHs, 4,197 reports)
Reconciliation
admission
MAR variance
Written order
Drug distribution
system
2005 (25 CAHs, 3,897 reports)
Computer entry
Workflow disruption
Communication
Documentation
Transcription
inaccurate/omitted
Performance/human
deficit
Procedure/protocol
not followed
Reporting Causes
Causes of Errors Errors (B -I) Jan 2005 - June 2007
2007 (31 CAHs 2,799 reports)
25%
20%
15%
10%
5%
0%
Reporting Contributing Factors
Contributing Factors to Errors (B -I) Jan 2005 - June 2007
2005 (25 CAHs, 3,897 reports)
2006 (35 CAHs, 4,197 reports)
2007 (31 CAHs 2,799 reports)
35%
30%
25%
20%
15%
10%
Range orders
Staff agency,
temporary
Emergency
situation
Patient transfer
Shift change
None
No 24 hour
pharmacy
Staff
inexperienced
Workload increase
Distractions
0%
Staffing insufficient
5%
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What we heard about using
MEDMARX as the foundation for
reporting in Critical Access Hospitals:



“Before the project, we just counted errors. We never
went past the type of error.”
“Using MEDMARX increased reporting because people
had more knowledge that what we are doing is intended
to make the system safer.”
“Using the lingo of MEDMARX, errors got broken
down into categories that even the board could
understand so they were more open to thinking about
allocating money for an automated dispensing system.”
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What we heard continued…

“Without the language of errors associated with
MEDMARX, all we could talk about was who did it and
not what happened and why. MEDMARX created a
standardized process that allowed us to collect more
information. The use of MEDMARX and its graphs and
charts contributes to the perception of errors as having a
system source.”

“Because we were able to visualize the system through
the graphs and charts, we could communicate to staff
and take action.”
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