How Pharmacists Can Improve Error Reporting Systems

Although error reporting systems can prove to be important tools in improving medication safety, these systems are not used to their full potential, according to the Institute for Safe Medication Practices (ISMP).

At the ASHP 2017 Summer Meetings and Exhibition in Minneapolis, Minnesota, Director of Error Reporting Programs Matthew Grissinger, RPh, FISMP, FASCP, discussed the value of error reporting systems, explaining that such systems help to identify and correct safety issues while encouraging communication among health care teams.

“Error reporting systems help to promote a culture of open communication,” Grissinger said. “They promote the concept that each employee is an important contributor to improvements.”

However, Grissinger noted that these systems rely on pharmacists and other health care providers reporting errors as they encounter them; when health care providers fail to report errors in an appropriate or timely manner, he explained, these systems do not work as intended.

Some of the most common factors that contribute to low rates of error reporting among pharmacists include:

• No clear definition of what constitutes a medication error
• Complex reporting processes
• Lack of time
• Fear of punishment or ridicule
• Reluctance to report incidents involving other staff members
• Concerns about medication error rates

Grissinger also suggested that many pharmacists may be reluctant to report medication errors if they do not receive feedback on their previous reports or if they feel that their concerns were not adequately addressed.

“Nothing will kill an error reporting system like staff feeling that their insights don't matter,” Grissinger stated.

Nevertheless, Grissinger emphasized that pharmacists regularly catch and correct medication errors on their own, and recommended that pharmacies work on cultivating an environment in which staff members are more willing to formally report these errors. He also advised pharmacy staffs to avoid collecting reports for their own sake, but instead to use those reports to make changes that can minimize future errors.

“I think pharmacists are already catching a lot of potential harmful errors and quantifying and identifying the most common calls that they are making as an example or most common conventions they are catching doing rounds,” Grissinger told Pharmacy Times. “They could help identify a potential, dangerous situation by proving or just demonstrating what they are already doing.”

References

• Grissinger M. Improving Your Error Reporting Program. Presented at: ASHP Summer Meetings and Exhibition. June 4-6, 2017. Minneapolis.